Documentation and Reimbursement for Testing

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Sep 21st, 2015 - Reviewed/Updated Aug 7th

The medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition that warrants the test(s).

TC - Technical component Modifier may be used.

Examples of documentation requirements of the ordering physician/nonphysician practitioner (NPP) include, but are not limited to,

• history and physical or exam findings that support the decision making
• problems/diagnoses, relevant data (e.g., lab testing, imaging results)

Documentation requirements of the performing laboratory (when requested) include, but are not limited to,

• lab accreditation
• test requisition
• test record/procedures
• reports (preliminary and final)
• and quality control record

Documentation requirements for lab developed tests/protocols (when requested) include

• diagnostic test/assay
• lab/manufacturer
• names of comparable assays/services (if relevant)
• description of assay, analytical validity evidence
• clinical validity evidence
• clinical utility

Providers are required to code to specificity however, if an unlisted CPT code is used the documentation must clearly identify the unique procedure performed. When multiple procedure codes are submitted on a claim (unique and/or unlisted) the documentation supporting each code should be easily identifiable. If on review the contractor cannot link a billed code to the documentation, these services will be denied based on Title XVIII of the Social Security Act, §1833(e).