Documentation and Reimbursement for Testing

by  Christine Woolstenhulme, CPC, CMRS, QCC, QMCS
September 21st, 2015

The medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition that warrants the test(s).

TC - Technical component Modifier may be used.

Examples of documentation requirements of the ordering physician/nonphysician practitioner (NPP) include, but are not limited to,

Documentation requirements of the performing laboratory (when requested) include, but are not limited to,

Documentation requirements for lab developed tests/protocols (when requested) include

Providers are required to code to specificity however, if an unlisted CPT code is used the documentation must clearly identify the unique procedure performed. When multiple procedure codes are submitted on a claim (unique and/or unlisted) the documentation supporting each code should be easily identifiable. If on review the contractor cannot link a billed code to the documentation, these services will be denied based on Title XVIII of the Social Security Act, §1833(e).



Documentation and Reimbursement for Testing. (2015, September 21). Find-A-Code Articles. Retrieved from

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