YNHH Laboratory Manual

Federal and State reimbursement regulations require that all tests ordered be documented as medically necessary for the care of the patient. Failure to do so can result not only in failure of reimbursement to the Hospital but also in governmental audit of the billing practices of the health care provider. The documentation for laboratory testing requires, at a minimum, (a) that the signature of the person legally authorized to order the tests is included either on the order requisition or in the chart where the rationale for the test ordering is included (usually the standard daily or outpatient note); (b) that the order clearly includes the name of the responsible attending physician; and (c) that the order slip or electronic process indicates the diagnosis for which the specific test is requested, preferably as the ICD-9 code associated with the diagnosis.

Updated: Sep-2007