The contractor cannot require the individual ordering of laboratory tests and laboratories are not prohibited from billing tests that are not individually ordered. When the modifier is submitted, the contractor has the discretion to consider the services to be medically necessary and will not request additional information. Also, there are many tests where a contractor may not have explicit policy and would, in the interim, accept individual ordering by a physician to be sufficient reason to presume the test to be medically necessary. The contractor retains the authority to request additional information if they determine that documentation showing individual ordering is not sufficient to support the medical necessity of the laboratory service. For example, if a contractor has local medical review policy that requires specific conditions to be present in order for a test to be considered medically necessary, the presence of the modifier may not be sufficient.
Contractors retain the authority to review any claim.
It is expected that contractors will perform some limited review of claims submitted with modifier QP to confirm that documentation exists and the modifier was not used in a fraudulent manner.