Medical Review of Diagnostic Laboratory Tests

6.9.1 – Medical Review of Diagnostic Laboratory Tests (Rev. 850, Issued: 12-14-18; Effective: 12-17-18; Implementation: 12-17-18) 42 CFR §410.32 states that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary and that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. Pub. 100-02, Chapter 15, Section 80.6.1 states that while a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed. Contractors shall consider order requirements for diagnostic laboratory tests met if there is: 1. A signed order or signed requisition listing the specific test; or 2. An unsigned order or unsigned laboratory requisition listing the specific tests to be performed AND an authenticated medical record that supports the physician/practitioner’s intent to order the tests (e.g. “order labs”, “check blood”, “repeat urine”); or 3. An authenticated medical record that supports the physician/practitioner’s intent to order the specific tests. See Pub. 100-08, Chapter 3, Section 3.3.2.4 for authentication requirements. Regardless of how the order requirements are met, contractors shall verify that the supporting authenticated medical record documentation contains sufficient information supporting the ordered/provided tests are reasonable and necessary per 42 CFR §410.32. Note: As noted in Pub. 100-02, Chapter 15, Section 80.6.1, if the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records.