Lab Test Order Requirements

You, the physician, practitioner, or non-physician practitioner who’s treating the patient (and who provides consultation or treats them for a specific medical problem and uses the results to manage their specific medical problem), must order the tests. Tests you haven’t ordered for treating the patient aren’t reasonable and necessary.

Document medical necessity in the patient’s medical record when ordering the service.

The entity submitting the claim must keep documentation from you, which includes:

• Documentation of the order for the service billed (including information that allows us to find and contact the ordering provider)
• Documentation showing correct order processing and claim submission
• Diagnostic or other medical information you provided to the lab (including any ICD-10-CM code or narrative description)

Diagnostic lab test orders require 1 of these:

• A signed order or signed prescription listing the specific test
• An unsigned order or unsigned lab prescription listing specific tests done
• An authenticated medical record that supports your intent to order specific tests

You can deliver an order through:

• Written and signed document that’s hand-delivered, mailed, or faxed to the testing facility. We don’t need your signature on orders for clinical diagnostic tests paid based on the clinical lab fee schedule, based on the physician fee schedule, or for physician pathology services.
• Call from you or your office to the testing facility.
• Email from you or your office to the testing facility.

Section 80.6 of the Medicare Benefit Policy Manual, Chapter 15 has more information.

The Complying with Medical Record Documentation Requirements and Complying with Medicare Signature Requirements fact sheets provide more guidance.

Medical record documentation should include enough information to show the ordered or provided tests are reasonable and necessary, per 42 CFR 410.32.

Signature and date stamps aren’t allowed, with a few exceptions.

“Other” Errors

“Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Refill Requirements

In some cases, a practitioner may find a patient’s expected, ongoing medical need and may write an order for DMEPOS for immediate use and refills for later dates.

Before refilling orders for DMEPOS products, suppliers must contact the patient to make sure a refill is needed. Don’t automatically ship a refill on a pre-determined basis, even if the patient authorizes it.

The supplier must document contact with the patient or their representative and verify the need for the refill. This documentation must include the following:

• Evidence the patient or their representative has confirmed their need to refill the supplies within 30 calendar days from the expected end of the current supply. Patients don’t have to count the remaining supply.
• We require the following before shipping the product:
  • Patient’s name
  • Date of contact
  • Item requested
  • Confirmation from the patient
  • Explanation of the need for the refill
• For items obtained in person from a retail store, we consider 1 of these as enough documentation for a refill request:
  • The delivery slip signed by the patient or their representative
  • A copy of the itemized sales receipt

You may use any means of communication to contact the patient to get their confirmation for the refill of the supplies, but you must include it in the documentation. For example, you can use automated text messaging or email to show the patient’s name, items, date of contact, and response. The documentation must be available to us upon request.

Don’t deliver the DMEPOS supply refill sooner than 10 calendar days before the end of usage for the current product.

Resource

Refillable DMEPOS Documentation Requirements