Complying with Documentation Requirements for Laboratory Services – MLN Fact Sheet

ORDERING OR REFERRING SERVICES

If you bill laboratory services to Medicare, you must obtain the treating physician’s signed order (or progress note to support intent to order) and documentation to support medical necessity for ordered services. These records may be housed at another location (for example, a nursing facility, hospital, or referring physician’s office).

If you order diagnostic services for Medicare patients, you must also maintain documentation of the order or intent to order and medical necessity of the services in the patient’s medical record.

Cooperation between ordering and referring providers and facilities that perform diagnostic tests is crucial to reducing errors and avoiding claim denials.

Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/ICN909221.html?DLPage=1&DLEntries=10&DLFilter=Laboratory%20Services&DLSort=0&DLSortDir=descending