Documentation of ordered test

Q:

In order to be able to count a test (ex: lab, x-ray), must the order be documented in the office note or just anywhere in the chart for that day to count?

A:

Based on review of available payer information including Medicare, the treating/ordering physician or qualified healthcare professional (QHP) must clearly document, in the medical record, the order and documentation supporting medical necessity for the ordered test. 

Additionally, according to analysis by Medicare’s Comprehensive Error Rate Testing (CERT) program, there has been an increase in billing errors related to diagnostic lab services due to the absence of documentation supporting the physician’s/QHP’s orders.   

Therefore, our best practice recommendation is to include the specific lab order in today’s encounter note.

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