Documentation for Bacterial Culture Lab Orders

by  Medicare Learning Network
March 8th, 2018

The Medicare Learning Network provides guidance on delivering orders for bacterial culture laboratory tests and required documentation:

An order may be delivered via the following forms of communication:

• A hand-delivered, mailed, or faxed written document signed by the provider and sent to the testing facility. Written orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or the physician pathology services do not require a signature. However, the medical record documentation must show the provider’s intent to order and the medical necessity for the testing.
• A telephone call by the treating provider or provider’s staff to the testing facility. Both the provider and testing facility must document the telephone order in their respective beneficiary medical records. While the telephone order does not require a provider’s signature, the beneficiary’s medical records maintained by the provider must show the provider’s intent to have the test performed.
• An email by the treating provider or provider’s staff to the testing facility. (See Medicare Benefit Policy Manual, Chapter 15, Section 80.6 - Requirements for Ordering and Following Orders for Diagnostic Tests.)

References:

• MLN Fact Sheet: Provider Compliance Tips for Laboratory Tests - Bacterial Cultures