QUESTION: CLAIMS: I received a denial stating the documentation submitted did not support the medical necessity of laboratory services. Can you tell me what I can submit to support these services?
Answer
Laboratory, diagnostic, and therapeutic procedures - MD order and progress notes showing medical necessity are needed.
Requisition forms or MD order form needed with MD signature.
Illegible MD signatures
Signature key or attestation statement is needed if MD signature illegible - by MD or Compliance Officer with typed name and MD signature
Alert treating physicians and medical records staff
Progress note by ordering physician is needed also to show the medical necessity of the services ordered. MD signature also needed with progress note.
Signature key or attestation statement is needed if MD signature illegible - by MD or Compliance Officer with typed name and MD signature
Providers with electronic ordering or progress notes systems
Print of screen showing electronic order or progress note (Include notation such as “Electronically signed by”.)
One copy per provider of the protocol that describes that the system is entered by the MD with a unique ID and password or audit trail showing MD entered system with unique ID and password
Alert medical records staff
For verification of illegible signature - Signature attestation example: “I, _[print full name of the physician/practitioner]_, hereby attest that the medical record entry for _[date of service]_ accurately reflects signatures/notations that I made in my capacity as __[insert provider credentials, e.g., M.D.]_ when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.” M.D. Signature.
