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Fact Sheet
Provider Compliance Tips for Laboratory Tests – Blood Counts
What’s Changed? Updated information to include 2020 data.
You’ll find substantive content updates in dark red font.
Introduction This publication educates providers on proper documentation and billing for blood count laboratory tests.
Provider Types Affected Physicians and non-physician practitioners (NPPs) who write requisitions or orders for blood count laboratory tests.
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Background The complete blood count (CBC) is a common laboratory test that includes a hemogram and differential white blood count (WBC). The hemogram includes a count of red blood cells, WBC, and platelets, as well as the finding of hemoglobin, hematocrit, and indicators.
The Medicare Fee-for-Service (FFS) improper payment rate for blood count lab tests for the 2020 reporting period is 11.1% with a projected improper payment amount of $28.1 million.
Reasons for Denial For the 2020 reporting period, insufficient documentation accounted for 86.4% of improper payments for lab tests. Blood counts and incorrect coding accounted for 13.6% of improper payments.
How to Prevent Denials
• You (the physician or NPP) who consult or treat a patient for a specific medical problem and use the test results to manage the patient’s medical problem must order the laboratory tests. Tests you don’t order for treating the patient aren’t reasonable and necessary. • Keep documents of medical necessity for services you order in the patient’s medical record. • The entity sending the claim must keep documents from you that show the correct processing of the order, submission of the claim, and diagnostic or other medical information you supplied to the laboratory, including any ICD-10-CM code or narrative description.
Orders Diagnostic laboratory test orders require: • A signed order or signed requisition listing the specific test or • An unsigned order or unsigned laboratory requisition listing the specific tests done and an authenticated medical record that supports your intent to order the tests (for example, order labs, check blood, or repeat urine) or • An authenticated medical record that supports your intent to order the specific tests
Note: For more information about order requirements, refer to the Medicare Program Integrity Manual, Chapter 6, Section 6.9.1.
Orders are delivered by: • Your written and signed document that is hand delivered, mailed, or faxed to the testing facility. Medicare doesn’t need your signature on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services.
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• A telephone call from you or your office to the testing facility. • An email from you or your office to the testing facility. For more information on Requirements for Ordering and Following Orders for Diagnostic Tests, refer to the Medicare Benefit Policy Manual, Chapter 15, Section 80.6.
Note: If you deliver the order by telephone, you or your office and the testing facility must document the telephone call in your copies of the patient’s medical records. You don’t need to sign the physician order, but you must clearly document the need for the test in the medical record.
Resources
• 2020 Medicare Fee-for-Service Supplemental Improper Payment Data • Code of Federal Regulations, Chapter 42, Section 410.32 • Medicare.gov • Medicare Benefit Policy Manual, Chapter 15, Section 80.6 • Medicare Program Integrity Manual, Chapter 6, Medicare Contractor Medical Review Guidelines for Specific Services, Section 6.9.1 • The National Coverage Determination (NCD) for Blood Counts
The Center for Program Integrity/Provider Compliance Group Policy Disclaimer Contact your MAC for any updates or changes to the Policy Article (PA) and the Local Coverage Determination (LCD) regarding policy and general documentation requirements.
Medicare Learning Network® Content Disclaimer, Product Disclaimer, and Department of Health & Human Services Disclosure The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).
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