Updated MLN Fact Sheet – Complying with Laboratory Services Documentation Requirements

Updated Section in Documentation Requirements:

The physician should clearly indicate all tests to be performed (for example, “run labs” or “check blood” by itself doesn’t support intent to order) when completing progress notes. Medical review contractors will consider diagnostic test order requirements met if there’s:

● A signed order or requisition listing the specific test

● An unsigned order or requisition listing the specific test(s) and an authenticated medical record supporting the physician’s intent to order the tests (for example, “order labs”, “check blood”, “repeat urine”

● An authenticated medical record supporting the physician intent to order specific tests

Updated Section in Ordering or Referring Services:

While a signature isn’t required on the physician order, the physician must clearly document in the medical record their intent to perform the test.

Providers should be aware of the various meanings of the term “standing orders.” Some understand this to mean recurring orders specific to the care of an individual patient. Others interpret this as routine orders for services delivered to a population of patients. Only medically necessary services ordered and rendered, including those based on treatment protocols, are considered for reimbursement when documentation supports the orders and/or protocols are individualized to each patient.

Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/ICN909221