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What Labs Need to Know About Proper Documentation for Billing

by | Sep 21, 2023 | News, Open Content

Billing and coding consultant Diana Voorhees shares her tips to ensure compliance when billing laboratory services.

According to a recent G2 Intelligence Lab Compliance Advisor article, most compliance problems with billing for laboratory services are caused by a lack of documentation. Such documents include signed doctor’s orders, signed office visit notes, and signed progress notes. In the article, billing and coding consultant Diana W. Voorhees, MA, MLS(ASCP)SH, CLCP, CPCO, highlights two key areas that such documentation must support:

  1. The intent to order a service
  2. The medical necessity of ordered services

Voorhees points to a December 2020 Medicare Learning Network (MLN) article as a helpful resource for labs on documentation requirements. She also adds her tips for what laboratory reports and requisition forms should include to ensure they support medical necessity and help labs avoid any compliance issues. Some of these tips include:

  • Ensuring lab reports are filed in the patient record
  • Ensuring the treating physician circles any abnormal results
  • Ensuring proper ICD-10 codes are used in requisition forms, while avoiding the use of preprinted codes

In addition to other advice on how labs can avoid the most pressing concerns related to the lab ordering process, Voorhees stresses the importance of cooperation between laboratories and ordering and referring providers to avoid compliance issues.

To read the full article, “How to Ensure Proper Documentation for Billing Laboratory Services,” log in to your Lab Compliance Advisor subscription.