CERT Denials Related to Orders for Laboratory & Pathology Testing

This article applies to independent clinical/pathology labs and in-house office laboratory services performed by medical practices. To better address problems identified during reviews conducted by the CERT contractor, the Palmetto GBA medical review staff examined records for several claims related to laboratory errors for which denials for testing procedures were generated.

Problematic “Ordering” Trends Noted During Review Process

• Absence of any type of requisition, order, or valid documentation of “intent” by the ordering-treating physicians or qualified NPPs
• Preprinted test requisition forms did not include signature/initials of the ordering/treating physicians or qualified NPPs, although the other required elements of these forms were correctly completed (handwritten and legible)
• Preprinted laboratory requisitions or orders were completed and signed/initialed only by auxiliary staff-not the ordering physician or qualified NPP
• For laboratory services performed and submitted by practices in-house (office), the patients’ charts or progress notes were somewhat illegible, did not list or even mention the tests or blood draws, and/or did not meet Medicare’s signature requirements.

Independent Clinical/Pathology Labs – Please Communicate With Your Clients

Independent clinical laboratories and their respective clients, i.e., ordering physicians or qualified NPPs, have a shared responsibility to cooperate and comply in providing necessary records when contacted as part of a review.

Palmetto GBA has found when the ordering/treating practitioners’ staffs are contacted directly by CERT, the offices fail to respond to direct requests for corroborating documentation, orders, chart notes, etc. Furthermore, when information is supplied, the patients’ records are often unacceptable because the records are unsigned and/or omit any reference to the tests being ordered.

If ordering practitioners do not reply to CERT follow-up requests, or send insufficient/invalid records, Medicare must hold the billing laboratory financially responsible for any incorrect payments.