Checklist: Clinical laboratory
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests pertaining to clinical laboratory services. It is not intended to replace the published guidelines. Health care providers retain responsibility to submit complete and accurate documentation.
| Check |
Documentation description |
|---|---|
| Documentation is for the correct beneficiary and date of service. | |
| Documentation is complete, legible, signed and dated by the physician or clinician. | |
| Documentation to support a signed order for laboratory test or medical records to support the intent to order by the treating physician, (e.g., signed office visit note, signed progress note, or signed physician order/requisition) |
|
| Signature attestation or signature log (for illegible signatures) from physician's progress notes supporting medical necessity or intent to order. | |
| Documentation to support the medical necessity of the laboratory tests ordered in accordance with all Medicare regulations and any applicable NCDs or jurisdiction N LCDs. |
|
| Documentation to include laboratory test results. |
|
| If applicable and required, submitted documentation should include a beneficiary waiver of liability. |
Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.