When providing any lab work the following is the updated documentation information for your chart notes. This is for biopsy, saliva tests, or any other tests you perform in your practice.
According to WPS the following documentation is required:
• Clear indication of patient name, date of birth, and date of service
• Lab results for date(s) of service billed
• Signed and dated physician order or progress/clinic/visit notes that clearly document the specific service(s) to be performed
• Documentation to support the medical necessity of ordered test(s)
• Medical diagnosis
• Signs and symptoms (rationale for lab performed)
• If handling is billed you must document who sent it out to lab and who put all docuemntation notes in chart, plus the doctors signature.
collection is billed: