When filing laboratory results in a patient's electronic health record, which information must be verified to correctly link the report to the services billed so that medical-necessity and reimbursement requirements are met?
The accession number and the date and time the specimen was collected
Reference range values and measurement units for every reported analyte
The ordering provider's NPI number and electronic signature
The ICD-10 diagnosis code(s) supporting the test and the associated CPT/HCPCS procedure code(s)
Each laboratory result should be documented with the ICD-10-CM diagnosis code(s) that justify the test and the corresponding CPT or HCPCS code(s) billed for the service. Matching these codes allows payer edits to confirm that the ordered test is reasonable and necessary, prevents claim denials, and maintains a clear clinical audit trail. Specimen identifiers, reference ranges, or provider signatures are important for other reasons but do not establish the required diagnosis-to-procedure linkage.
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