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).
References/Resources
About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.
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