Medicare Billing


Medicare Billing

Successful Laboratory Requisitions, Medicare Billing

The following Medicare billing requirements will help you to accurately complete laboratory requisitions, which will minimize follow-up calls for clarification or to capture missing information. Thank you for your attention to detail.

When billing Medicare, the following information is always required on the laboratory requisition unless marked as (optional).  The optional information is to assist in billing.

1.            Patient's full name

2.            Patient's sex

3.            Patient's date of birth

4.            Patient's phone number (when patient is in a SNF, stamped phone number in this area is sufficient)

5.            Patient's full address

6.            Ordering provider full name

7.            Ordering provider signature (optional)

8.            Date and time of collection and fasting status

9.            Who is to be billed (check healthplan, and in healthplan name specify Medicare or the Advantage contractor)

10.          Patient's Social Security Number (optional)

11.          Insurance ID number (Medicare HIC # + Prefix or suffix character(s))

12.          Marked Test(s) being ordered with appropriate and valid ICD10 for every test ordered

13.          When indicated, a signed and dated ABN-with test(s) listed, reason(s) specified for possible denial and estimated cost of test(s) with the patient checking the option desired and the patient signing and dating the ABN.

Laboratory testing orders may be submitted to us using our requisition, a client's custom requisition, or electronically via an interface. Regardless of the format used to submit orders, the fields numbered below indicate required data for a successful laboratory order.


Documentation Requests, Medicare Billing

We, as the Laboratory, perform tests requested for your patients who have Medicare. We are required, by law, to provide documentation if requested by the Comprehensive Error Rate Testing (CERT) program by CMS. CERT reviews claims, on a post-payment review of claims, submitted by our laboratory. These claims could be audited for documentation to support the rendering/billing provider indicated on the claim. During the audit process, if documentation is needed, the physician or supplier (lab) must provide the required documentation within the deadlines stipulated in the written request from CERT.

The lab receives these CERT requests and must request patient records, progress notes, etc. from the physician’s office and/or clinic. Therefore, it is critical for each office/clinic to understand that we have time limits to receive this information and must respond to Medicare within the timeframe given to the laboratory. Upon receipt of documentation, CERT reviews the claims and medical records from the providers/suppliers who submitted the claims, reviewing the claims for compliance with Medicare coverage, coding, and billing rules.

Below are the guidelines from Medicare to assist in documentation and provide guidance to follow when ordering Laboratory tests.

Documentation Guidelines for Medicare Services

This article is being revised and reprinted from "Medicare B News," Issue 236 dated April 17, 2007, to ensure that the Novitas Solutions (Novitas) provider and supplier community has access to recent publications that contain the most current, accurate and effective information available.

Medical records should be complete, legible, and include the following information:

•             Reason for encounter, relevant history, findings, test results, and date of service.

•             Assessment and impression of diagnosis. • Plan of care with date and legible identity of the observer.

•             Documentation that supports that the rendering/billing provider indicated on the claim is the healthcare professional providing the service. (*Note)

•             Records should not only substantiate the service performed, but also the required level of care.

If the physician uses a scribe (an individual taking notes), the scribe needs to fully sign the note, with their own credentials, followed by the physician’s signature and credentials.

Documentation Requests, Medicare Billing

* Note: Medicare needs to identify primary physicians/practitioners of a service not only for use in standard claims transactions, but also for review, fraud detection, and planning policies. In order to accomplish this, Novitas must be able to determine and verify the rendering physician/practitioner for each outpatient service billed to Medicare. It is very important that the individual(s) performing a billed service is/are identified.

By law, Medicare contractors [Medicare Administrative Contractors (MAC) Part B Carriers and Medicare Administrative Contractors (MAC) Part A Fiscal Intermediaries] can review any information, including medical records, pertaining to a Medicare claim. Providers billing Medicare for their services must act in accordance with the following conditions:

Document in appropriate office records and/or hospital records each time a covered Medicare service is provided or ordered. In the case of laboratory test orders, the exact name of the test(s) being ordered needs to be in the patient's medical record.

When providing concurrent care for hospital or custodial care facility patients, physicians should identify their specialty in order to help support the necessity. Write medical information legibly and sign each entry with a legible signature, or ensure that the provider’s/author’s/observer’s identity is present and legible.

Medical information should be clear, concise, and reflect the patient's condition.

Sign progress notes for hospital and custodial care facility patients with all entries dated and signed by the healthcare provider who actually examined the patient. Provide sufficient detail to support diagnostic tests that were furnished and the level of care billed.

Do not use statements such as “same as above” or ditto marks (“). This is not acceptable documentation that the service was provided on that date. The “burden of proof” remains with the provider to substantiate services and/or supplies billed to Medicare. During the audit process, if documentation is needed, the physician or supplier must provide the required documentation within the deadlines stipulated in the written request.

Advance Beneficiary Notice, Medicare Billing

The Omnibus Budget Reconciliation Act of 1986 (OBRA) included a limitation of liability (or waiver of liability) provision that provided beneficiaries with protection from liability when they, in good faith, receive services from a Medicare provider for which Medicare payment is subsequently denied as not "reasonable and necessary."

An Advance Beneficiary Notice (ABN) should be obtained whenever a provider has reason to believe a procedure could be denied as not reasonable and necessary. Generally, services necessitating a signed ABN are those that are payable in some instances, but not payable in others. These can include:

·         Screening Tests:  Tests that might be ordered as part of a routine exam (when the patient does not exhibit evidence of a particular disease) are not covered.

·         Experimental ("Investigational") Tests:  Tests designated by the manufacturer as "for research or investigational use," and thus considered experimental or investigational, are also not covered by Medicare.

·         Tests Performed Too Frequently:  Tests that are performed more frequently than is recommended by Medicare are not covered.

·         NCD or LCD Tests:  Laboratory tests for which Medicare has established either a National Coverage Decision (NCD) or for which a Medicare Administrative Contractor (MAC) has established a Local Coverage Decision (LCD).

·         Tests Not Medically Necessary:  Tests that are not medically necessary for a diagnosis or condition - in Medicare's opinion - are not covered.

·         Specifically Excluded Tests:  Laboratory tests that are specifically excluded by the Medicare program. (e.g., General Health Panels)

Please provide an ICD-10 code for each test ordered for Medicare patients.

Please provide the laboratory with a valid Advance Beneficiary Notice when you have reason to believe Medicare may deny a procedure as 'medically unnecessary.'

The procedure for obtaining a Medicare Advance Beneficiary Notice (ABN) is based on the current list of tests for which Medicare requires a specific ICD10 code to consider payment. Please refer to the "Current Lab Services That Require Proof of Medical Necessity" list. Do not obtain a Medicare ABN for every Medicare patient but only for those who may be held liable for the service.

Medicare is very specific about what elements are required on an ABN for it to be considered valid. Absence of any of the required elements invalidates that ABN and is the same as no ABN at all. Medicare is also very specific about format and appearance of the ABN. Please take a moment to review the ABN that follows. The following must be completed on each ABN obtained:

1.       Patient Name

2.       Date of Birth or other unique identifier as Identification Number. Must not use Medicare numbers (HICNs) or SSN.

3.       Specific tests the patient was advised could be denied must be listed in the appropriate column.

4.       The reason these tests may be denied must be listed in the appropriate column.

5.       The estimated cost of the test(s), to the best of your knowledge, must be provided in the appropriate column.

6.       Once the information is recorded, ask the patient to read, and then check Option 1, Option 2, and or Option 3. The patient must do this.

7.       Patient must sign the ABN.

8.       Patient must date the ABN.


The ABN Request Program

Please provide the laboratory with a valid Advance Beneficiary Notice when you have reason to believe Medicare may deny a procedure as 'medically unnecessary.'

PLS provides ABN assistance through our Provider Portal, when using our Web Order system.



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