Laboratory Services Documentation Requirements | What You Need to Know 

The laboratory industry has experienced an increasing number of reimbursement recoupments by payors who have determined that a test requisition that is not signed by the ordering practitioner is not sufficient to establish the practitioner’s intent to order the testing.  As a valued client of Clinical Pathology Laboratories it is important for us to continue to work together to assure that we have sufficient documentation to support intent to order.  

Most payers are now demanding your office notes or other medical documentation to support claims for testing when the test requisition is not signed. While there is still some uncertainty as to whether a “physician signature” on a test requisition, by itself, will be sufficient to support all claims, it is clear that if we have your signature on test requisition forms, we will likely reduce significantly the number of occasions when we need to subsequently request medical record documentation from you or your staff to support our claims.   

It is important that the following be utilized when ordering laboratory services: 

Payor Documentation Requirements: 

  • Signed manual requisition
    • All manual requisitions have a place for the physician’s signature
  • Signed Electronic (EHR) order
    • Please include ordering physician e-signature section on the form (In the event that the electronic requisition does not display the ordering clinician’s e-signature, the hard-copy e-requisition accompanying the specimen must be signed.)

In the event of a Payor Audit: 

  • Unsigned physician orders or unsigned requisitions alone do not support physician intent to order.
  • Unsigned orders could potentially result in burdensome documentation requests for you and your practice after the fact.
  • Attestation statements are unacceptable for unsigned physician orders or requisitions.

To minimize resources required for you and your team after services are ordered, please ensure your laboratory orders include your manual or e-signature on the requisition.  

Thank you again for your partnership, understanding and compliance with these payor mandates.  Please contact your local sales representative directly with any further questions. 

References:

CMS: Complying with Laboratory Services Documentation Requirements (December 2020)
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/LabServices-ICN909221-Text-Only.pdf