Documentation Responsibilities for Diagnostic and Laboratory Services
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When billing for laboratory or diagnostic tests, ensuring proper documentation is crucial to avoid claim denials during Medicare reviews. Here’s a quick overview:
- Physician’s Role: When ordering tests, physicians must provide clear documentation to justify the medical necessity of the test.
- Billing Provider’s Responsibility: If the test is being reviewed, the billing provider must collect the necessary documentation from the referring physician or facility.
- Collaborative Effort: Laboratories and physicians must work together to ensure medical orders and progress notes support the services billed. Without adequate documentation, payment could be denied.
- HIPAA Compliance: Sharing medical records with Medicare contractors does not violate HIPAA.
Proper documentation is a shared responsibility—ensure you’re working with your laboratory partners to avoid payment issues.
