How to avoid payment denials on two common diagnostic tests

If your office writes requisitions or orders for venipuncture and urinalysis tests (or routinely performs them in an office lab) for Medicare beneficiaries the Centers for Medicare & Medicaid Services (CMS) has released two new fact sheets to help you ensure you are being compliant with and properly paid for such services.

The fact sheet on routine venipuncture notes that most payment errors reported by CMS are triggered by questions about medical necessity. The fact sheet on urinalysis blames most payment denials on insufficient documentation. To avoid problems with either type of test, CMS advises you to meet the following conditions:

1.    The physician or non-physician provider (NPP) treating the Medicare beneficiary must be the one to order any diagnostic test. If someone else orders the test, Medicare will not consider the test reasonable and necessary.
2.    The physician or NPP who orders the service must maintain documentation of medical necessity in the beneficiary’s medical record.
3.    The entity submitting the claim must maintain documentation from the ordering physician or NPP and documentation that the information submitted with the claim accurately reflects the information from the ordering physician or NPP

– Kent Moore, Senior Strategist for Physician Payment at the American Academy of Family Physicians