by Medicare Learning Network
March 8th, 2018
The Medicare Learning Network provides guidance on how to prevent denials of Bacterial Culture Laboratory Tests and required documentation:
The following conditions must be met:
- Bacterial cultures must be ordered by the physician/NPP who is treating the beneficiary. The physician/ NPP is the one who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician/NPP treating the beneficiary are not reasonable and necessary.
- The physician/NPP who ordered the test must maintain documentation of medical necessity in the beneficiary’s medical record.
- Entities submitting a claim must maintain documentation received from the ordering physician/NPP.
Examples of documentation that may be requested for medical review of claims for laboratory tests, including bacterial cultures:
- Documentation of the order for the service billed (including information sufficient to enable CMS to identify and contact the ordering physician/NPP)
- Documentation showing accurate processing of the order and submission of the claim
- Diagnostic or other medical information supplied to the laboratory by the ordering physician/NPP, including any ICD-10-CM code or narrative description supplied