Documentation tips for bacterial culture lab tests

CMS determined the improper payment rate for bacterial culture lab tests was 15.1% in 2023, with a projected improper payment amount of $9.6 million. Insufficient documentation accounted for 100% of improper payments for these tests during this reporting period, according to the agency.

Revenue integrity professionals should review CMS’ provider compliance tip to better understand lab test order requirements and prevent denials.

The physician, practitioner, or non-physician practitioner who is treating the patient must order the test(s). The provider must be consulting or treating the patient for a specific medical problem and use the results to manage it.

Medical necessity must be documented in the medical record when ordering the service, according to CMS. The entity submitting the claim must have the following:

• Documentation of the order for the service billed, including the provider’s contact information
• Documentation showing correct order processing and claim submission
• Diagnostic or other medical information provided to the lab

Diagnostic lab test orders require one of the following:

• Signed order or prescription listing the specific test
• Unsigned order or lab prescription listing specific tests done
• Authenticated medical record supporting the intent to order specific tests

Providers can deliver orders via phone, email, or a written and signed document that is hand-delivered, mailed, or faxed to the testing facility, according to CMS. The agency does not need the provider’s signature on orders for clinical diagnostic tests paid based on the clinical lab fee schedule, based on the physician fee schedule, or for physician pathology services.

Revenue integrity professionals can read Chapter 6 of the Medicare Program Integrity Manual for more information on order requirements, as well as Chapter 15 of the Medicare Benefit Policy Manual for more information on delivery requirements. Access CMS’ fact sheets on medical record documentation requirements and Medicare signature requirements for additional guidance.