After reviewing examples of lab requisitions and test results obtained in the course of CERT reviews, Palmetto GBA wishes to reiterate the shared responsibilities of ordering physicians or qualified non-physician practitioners (NPPs) and clinical laboratories.
There are many versions of a clinical lab order. It may be a preprinted form, a handwritten note or completed using a secured online electronic order form such as an e-requisition. Regardless of the method, copies should be maintained by and available from independent clinical laboratories upon request. All should include, at a minimum, the following:
- Name of laboratory testing facility
- Name and address of ordering-treating provider
- Name of patient
- Patient identifying information, i.e., Medicare number, date of birth, etc.
- Date of specimen collection
- Listing of the specific tests being ordered (terms such as 'blood work' or 'lab work' alone are not acceptable)
- Corresponding diagnoses
- Signature* - Legible handwritten signature or a valid electronic signature of the ordering-treating provider
NOTE: 'Signature stamps' of practitioners would not be permitted for Medicare record-keeping purposes.
*This is currently optional under Medicare Part B guidelines for requisition forms and orders used by independent clinical laboratories for testing and Medicare Part B billing and payment consideration purposes.
To qualify for signature exemptions on laboratory requisitions, the services must be paid on the basis of the clinical laboratory fee schedule.
Ordering Physicians/NPPs – Medical Records
We have found the task of completing a laboratory order/requisition form is frequently delegated to auxiliary staff on instructions from the ordering-treating provider. Again, these forms are often unsigned or signed/initialed by the staff-not the physician or NPP. This is appropriate under Medicare guidelines for the laboratories’ own testing and billing purposes.
However, there must ultimately be written evidence of the physician’s or qualified non-physician practitioner’s direct involvement with the requested testing in the patient’s chart or medical records. These records are customarily maintained by physicians/NPPs at their office practice location or in a facility, e.g., nursing homes, and should be made available upon request.
For more information concerning this topic when medical reviews are conducted, please refer to our article, 'Independent Clinical Laboratories & Clarification of Signature Issues on Requisitions.'