Documentation requirements
Documentation must be adequate to verify that coverage guidelines listed above have been met. Thus, the medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition (ICD-10-CM code) that warrants the test(s).
Examples of documentation requirements of the ordering physician/nonphysician practitioner (NPP) include, but are not limited to, history and physical or exam findings that support the decision making, problems/diagnoses, relevant data (e.g., lab testing, imaging results).
Documentation requirements of the performing laboratory (when requested) include, but are not limited to, lab accreditation, test requisition, test record/procedures, reports (preliminary and final), and quality control record.
Documentation requirements for LDT(s)/protocols (when requested) include diagnostic test/assay, lab/manufacturer, names of comparable assays/services (if relevant), description of assay, analytical validity evidence, clinical validity evidence, and clinical utility.
When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 0027U | HCPCS | Covered |
| 0119U | HCPCS | Covered |
| 81105 | HCPCS | Covered |
| 81106 | HCPCS | Covered |
| 81107 | HCPCS | Covered |
| 81108 | HCPCS | Covered |
| 81109 | HCPCS | Covered |
| 81110 | HCPCS | Covered |
| 81111 | HCPCS | Covered |
| 81112 | HCPCS | Covered |
| 81120 | HCPCS | Covered |
| 81121 | HCPCS | Covered |
| 81161 |