April 16, 2008
Clinical Laboratory and Imaging Orders
Clinical laboratory and imaging tests are a routine part of most practices. Proper documentation is necessary to make sure that the test is correctly ordered, performed, reported and reimbursed.
The physician's clinic notes or hospital progress notes should clearly show what tests the physician wants ordered for the beneficiary. The clinic note or the hospital order must then be signed by the physician either physically or electronically.
Once ordered, the person actually completing the lab or imaging center's request should assure that the ordering physician's name is so noted on the requisition form and include the working diagnosis either verbatim or with an ICD-9 code. Ideally the physician should sign this sheet but understandably this is not always practical.
The clinic notes should be made available for CERT auditors reviewing lab and imaging claims upon request. The notes may also serve to remind the physician to review the chart for results and as a note for other providers as to what tests have been performed therein avoiding duplicative tests when not medically necessary.
The medical records containing the order should be maintained and be available to Medicare upon request.
