When is a medically necessary, routine venipuncture or urinalysis lab test not medically necessary under Medicare requirements?
OK, here’s the answer: When the test was ordered by someone other than the treating physician (which could include a nonphysician practitioner on the physician’s health care team).
By the way, the treating physician is the physician who is furnishing a consultation or treating the Medicare patient for a specific medical problem and who uses the results in the management of the patient’s specific medical problem.
The Centers for Medicare & Medicaid Services is paying attention to claims for these lab services because it has found they were paid in error in 2018 by some $28 million. For routine venipuncture, medical necessity errors accounted for virtually all the improper payments. For urinalysis, it was insufficient documentation.
Remember, for a lab test claim to be paid correctly:
- The treating physician must order all diagnostic laboratory tests (as well as diagnostic x-ray tests and other diagnostic tests). Tests not ordered by the treating physician are not reasonable and necessary under Medicare requirements.
- The physician who orders the service must document medical necessity in the patient’s medical record.
- The entity submitting the claim (such as a lab) must maintain the documentation it receives from the ordering physician and make sure it is accurately reflected in the information listed on the claim.
The treating physician can deliver orders to the lab via:
- A signed, written document, faxed, mailed, or hand-delivered. (No signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services. The physician must clearly document, in the medical record, his or her intent that the test be performed.)
- Phone call. Both the physician and the testing facility must document the phone call in their respective copies of the patient’s medical records.
For the full rules, see the Medicare Benefit Policy Manual, Chapter 15, Section 80.6 – Requirements for Ordering and Following Orders for Diagnostic Tests. See also: Correct Code for Billing a Routine Venipuncture.
Last Updated On
May 29, 2019