Please note, this communication applies to Healthy Blue + Medicare (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).

Blue Cross NC strives to ensure Healthy Blue + Medicare providers understand documentation compliance, and we are committed to educating Healthy Blue + Medicare providers in hopes of eliminating errors in documentation practices. It is a best practice and industry standard that physicians sign and date laboratory orders or requisitions. 

Although the provider signature is not required on laboratory requisitions, if signed and dated, the requisition will serve as acceptable documentation of a physician order for the testing, and it is strongly encouraged. In the absence of a signed requisition, documentation of your intent to order each laboratory test must be included in the patient’s medical record and available to Blue Cross NC upon request. Documentation must accurately describe the individual tests ordered; it is not sufficient to state “labs ordered.”

Blue Cross NC will consider laboratory order or requisitions requirements met with one of the following:

• A signed order or requisition listing the specific test(s)
• An unsigned order or requisition listing the specific test(s), and an authenticated medical record supporting the physician’s intent to order the test(s)
• An authenticated medical record (for example, office notes or progress notes) supporting the physician’s intent to order the specific test(s)

Attestation statements are not acceptable for unsigned physician order or requisitions.

Signature stamps are not acceptable.

References:

• Center for Medicare & Medicaid Services Complying with Laboratory Services Documentation Requirements (PDF)
• Center for Medicare & Medicaid Services Complying with Medicare Signature Requirements (PDF)
• Center for Medicare & Medicaid Services Medicare Provider Compliance Tips Blood Counts
• Title 42 CFR §410.32
• Reimbursement Policy C-20003 ; Documentation Standards for Episodes of Care – Professional Administrative

Access more provider information, forms, policies and resources for our Healthy Blue + Medicare plan.

NCBCBS-CR-005980-22-CPN5368 September 2022