When tests ordered are not listed in the documentation but billed, what should be done?

When tests ordered are not listed in the documentation but billed, what should be done?

• A. Ignore them
• B. Document the tests ordered on the date of service
• C. Copy from another patient
• D. List them on a separate note

Answer: (B)

Accurate, complete documentation must reflect every test that was ordered and billed, with the date of service clearly recorded. If a test is billed but not listed in the chart, there’s a mismatch between what was ordered and what the record shows, which can lead to claim denials, audits, and compliance concerns. The best course is to document the tests that were ordered on the date of service, tying the orders directly to that encounter, and including the rationale for the orders and any available results or statuses. This creates a clear audit trail and ensures the medical record supports the billing. If a test was ordered but not yet resulted, note that it was ordered on the service date and update the chart with results or status as they become available. Ignoring the discrepancy, copying from another patient, or listing the tests on a separate note would not provide the proper linkage between the encounter and the billed services.

Accurate, complete documentation must reflect every test that was ordered and billed, with the date of service clearly recorded. If a test is billed but not listed in the chart, there’s a mismatch between what was ordered and what the record shows, which can lead to claim denials, audits, and compliance concerns. The best course is to document the tests that were ordered on the date of service, tying the orders directly to that encounter, and including the rationale for the orders and any available results or statuses. This creates a clear audit trail and ensures the medical record supports the billing.

If a test was ordered but not yet resulted, note that it was ordered on the service date and update the chart with results or status as they become available. Ignoring the discrepancy, copying from another patient, or listing the tests on a separate note would not provide the proper linkage between the encounter and the billed services.