Wiki Abnormal Lab Findings

SWsibemom

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I work for a lab and on the order it states "elevated potassium" as the Dx. Since I don't have access to the chart notes, I don't know if this was determined based on a previous lab test or not, but I don’t know how else they would know it is elevated without a previous test. I assume it was based on a previous lab test, but we aren’t suppose to assume. Would you query the ordering provider or would you code it to abnormal lab findings? Your opinion is appreciated.
 
SWsibemom,
Hi, personally I would code what is provided on the lab requisItion. Reviewing the ICD book (Findings, abnormal, inconclusive, without diagnosis) potassium elevated "excess" would be E87.5 and that is what I would have assigned for this coding scenario.
Have a great evening,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT
 
When I studied for the CCS certification, Faye Brown's book (which many people use to study for the exam) stated that hyperkalemia has to be stated as such by the provider. It also states to code it to other abnormal blood chemistry. To me elevated doesn't necessarily mean excess. As a coder I can't diagnosis the condition so for this reason I don't code it to E78.5. My issue is that I don't know if it was diagnosed through blood or not. I assume so, but don't know if it was discovered through a urine potassium test or if the patient has a condition such as CKD or diabetes to cause the abnormal level. The choices as I see it is to query the provider or assign R79 category and assume it was discovered by blood testing.

I appreciate your input.
 
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If you are an independent lab, I cannot stress enough, based on experience, that you do not interpret a written documentation into diagnosis code. From a compliance standpoint this is not a best practice. Query the provider in writing, and have them provide you the diagnosis ensuring that that diagnosis code is in the progress note. As you said, you don't have access to the chart, and you CANNOT assume. If you were a laboratory in the physicians practice, or in a hospital, you could access the chart and progress notes to support your translation of the written documentation on the requisition. As an independent laboratory, from a compliance standpoint this is will create risk under audit, and if for some reason that translation triggers payment due to a diagnostic code edit then there is even more issue. I work with so many billers and coders that are now in the clinical laboratory space who do not understand the nuance of this separation, but it is critical.
 
If you are an independent lab, I cannot stress enough, based on experience, that you do not interpret a written documentation into diagnosis code. From a compliance standpoint this is not a best practice. Query the provider in writing, and have them provide you the diagnosis ensuring that that diagnosis code is in the progress note. As you said, you don't have access to the chart, and you CANNOT assume. If you were a laboratory in the physicians practice, or in a hospital, you could access the chart and progress notes to support your translation of the written documentation on the requisition. As an independent laboratory, from a compliance standpoint this is will create risk under audit, and if for some reason that translation triggers payment due to a diagnostic code edit then there is even more issue. I work with so many billers and coders that are now in the clinical laboratory space who do not understand the nuance of this separation, but it is critical.
Hi,

I agree that it is best for a lab to query. I am writing policies for the coders and want to get it right. Sometimes I have to talk it out to know that I am not creating needless busy work for the coders, but the queries are important piece to correct coding. I keep going back to what I was taught by saying, "can I stand in front of a judge and confidently justify my coding." Thank you for your response.
 
'Elevated' is a term that can be coded by itself - it does not require interpretation. There is an entry for 'elevated' in the alphabetic index. This will take you to the sub-heading 'findings on laboratory examination', which will in turn direct you that entry, under which you will find 'potassium', which lists E87.5 or E87.6 (hyperkalemia or hypokalemia). I would not use the R79 category because the 'excludes 2' note for 'diagnostic abnormal findings classified elsewhere' in that code section directs you back to the alphabetic index.

I don't think you are interpreting 'excess' here, since these are the only entries for abnormal potassium, so it is self-evident that E87.5 would be the only option for 'elevated'. I agree in general that interpretations of terms should not be made by coders, but in this case the term 'hyperkalemia' is actually synonymous with 'high potassium' - it is not a disease process, but a finding, so you are not inappropriately 'diagnosing' the patient by using this. So I believe that if a provider has documented 'elevated potassium', as was done on the lab requisition, the correct code is E87.5 - this is consistent with the coding process that's been followed everywhere I've ever worked and I've never encountered any auditor who would have cited this as an error.

While it is correct that you cannot interpret a lab result of high potassium to come up with a code, I think it is unnecessary to query the provider for additional information in this instance since the diagnosis of 'elevated potassium' was received from the provider and that is sufficient to support code assignment.
 
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Hi,

I agree that it is best for a lab to query. I am writing policies for the coders and want to get it right. Sometimes I have to talk it out to know that I am not creating needless busy work for the coders, but the queries are important piece to correct coding. I keep going back to what I was taught by saying, "can I stand in front of a judge and confidently justify my coding." Thank you for your response.

There are solutions so that your coders don't have to be and should not be responsible for this query as it can be generated automatically at the time the specimen is accessioned by the accessioner entering in an error code that will generate an electronic or fax notification directly back to the provider. Orchard, Apollo, Xifin, Avalon, and most of the other LIS systems all have this capability and it is something we build into our laboratory build outs. A missing or only narrative description on a requisition is what most labs will hold as a DNR or "Do Not Run" as without a valid diagnosis code the testing is not billable. Most independent laboratories only allow for the entry of a diagnosis code in their E-Req or paper requisition system, no narratives can be entered and the code then entered is validated before the requisition is even submitted.

Ultimately what I have seen get very tricky for laboratories that allow narrative diagnostic criteria to be interpreted is when they receive more than one test per specimen, and how then is a coder without access to the progress notes to know how to appropriately assign those narratives a diagnosis code and then to the testing ordered. If it helps I have included a draft policy and a copy of a form (similar to what I mentioned above) that we created for a laboratory that we helped launch a few years ago. Ultimately, whether a lab translates narrative diagnosis codes is a risk based decision each lab has to make, I will say it is just not a tenable situation if a laboratory processes more than 1,000 specimens a day to have your certified coding team (if you even have one) do this, which as you stated is your fear and I agree. If a provider is that lazy in his order, then I would also have concerns around his documentation.
 

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I will bring this up at our monthly compliance meeting and share the forms that have been provided. We have computer generated fax letters, but that doesn't occur until the accession hits the Business Office, but someone has to click for a letter to be sent, which is after the lab has been performed. This does concern me and as part of the education/compliance team, I want to make sure we are not creating undue work for the company as well as the community providers at the same time as being compliant and not creating risk. I appreciate the feedback.
 
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