Health Information Management

Q&A: Authentication is key to establishing medical necessity

APCs Insider, August 28, 2015

Want to receive articles like this one in your inbox? Subscribe to APCs Insider!


Q: We received a denial for services based on medical necessity. A Comprehensive Error Rate Testing (CERT) auditor reviewed our laboratory services claim against the medical record documentation and denied the services for lack of medical necessity. We submitted the medical record documentation, which consisted of the lab requisition and the lab results. The diagnosis on the requisition was a covered diagnosis and dates of service on the claim and the test results matched. We don’t know why we received this denial.
A: Was the lab requisition authenticated by the physician/non-physician practitioner (NPP)? If not, did your medical record documentation include the authenticated order from the physician/NPP?
CMS does allow lab testing to be performed based on a requisition, which by definition in the 2012 Medicare Physician Fee Schedule Final Rule is not required to be signed or authenticated. However, this does not negate the requirement that there must be a signed/authenticated physician order for the service – either in the physician office medical record or the facility/lab medical record. The provider may elect to sign the lab requisition, which may then serve as the order.
When medical records are requested to support a service, the provider who is billing for the service is responsible for providing all required documentation to support the service, including a signed and authenticated order. Without the authentication on an order, medical necessity is not established because the ordering provider has not validated that the test is necessary. This responsibility may require obtaining documentation from the treating/ordering provider’s office documentation. Without this, the documentation is deemed to be insufficient to support the medical necessity of the service and the claim can be denied.
In addition, if the signature is illegible, and the document does not provide a legible printed provider name, a signature log or attestation statement is required and should accompany the documentation provided to the CERT. Additional information related to signature/authentication requirements is located in the Medicare Program Integrity Manual, Chapter 3, section
Editor’s note: Denise Williams, RN, CPC-H, seniorvice president of revenue integrity services at Revant Solutions, formerly known as Health Revenue Assurance Associates, Inc., in Fort Lauderdale, Florida, answered this question.


Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular