Wiki abnormal lab results

[DarlaPaden]

If a patient had an abnormal vitamin D level result, can that be used as a diagnosis for that dos even if the provider did not mention it in the documentation? Also, my clinic only runs vitamin D levels on wednesdays so the provider would not have had this result until the following week, which is why they did not assign it as a diagnosis in the chart.

 

[thomas7331]

No, you cannot assign a diagnosis code for an abnormality without the provider's documentation. Automated lab results don't support a code unless the records reflect that the provider reviewed the results and agrees that the result reflects an abnormal condition for the patient. Per the ICD-10 guidelines, section I.A.19: "The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists.... Code assignment is not based on clinical criteria used by the provider to establish the diagnosis."

 

[DarlaPaden]

Thanks for that information, that is exactly what I thought, just wanted confirmation.