Awareness : OBC Tips

Submission of Diagnoses and Prohibited Practices for Clinical Laboratories

Only submit diagnoses submitted on claims to Medicare from the ordering physician.  Unlike pathologists and radiologists, clinical laboratories may not alter the diagnosis based on the findings of the test or procedure.  Medicare regulations require ordering physicians to include the ICD-10 codes or narrative diagnosis information with each and every order for lab tests.  The Balanced Budget Act of 1997 expanded this requirements to include non-physician practitioners such as physician assistants, ARNPs, and other laboratories.

Prohibited Practices given by the OIG are the following:

  • Laboratories are NOT to use information provided by a physician from earlier dates of service;
  • NOT to create diagnosis information that has triggered reimbursement in the past;
  • NOT to use computer programs that automatically insert ICD-10 codes without first receiving diagnosis information from the ordering physician;
  • NOT “make up information for claim submission purposes”.