Physician’s order for clinical laboratory services and diagnostic procedures

First Coast Service Options Inc. (FCSO) continues to see a large number of errors identified by the Comprehensive Error Rate Testing (CERT) contractor for clinical laboratory services and diagnostic procedures. The errors are largely due to the absence of a physician’s order on file or for failure to provide a copy of the order when documentation is requested. It is inappropriate to bill the Medicare program for clinical laboratory services and diagnostic procedures without a physician’s order. Many providers and facilities are being required to refund money to Medicare for not having a copy of the physician’s order, or for not providing it when requested.

Medicare guidelines require that supporting documentation for laboratory and diagnostic services must include:

• A copy of the physician’s/NPP’s order
• Documentation that the test was performed
• Record of the result/report

It is imperative that complete records are submitted for review when requested. Without the appropriate physician’s order, there is no way for Medicare or the CERT contractor to verify if a test was ordered or whether the exact test ordered was performed.