Wiki Can you pull a diagnosis from a test result?

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MEAH95

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We have a bit of a disagreement at my work on interpretation of test results.

An example would be: Patient is seen for CKD, congestive heart failure, hypertension and various other issues. The doctor never states the stage of CKD.

However he does have an estimated GFR in the test results.

Is it appropriate to pull the Estimated GFR and give the patient a stage of CKD?
Or
Should the provider be queried to give their clinical opinion of the patients status?

Any references or resources you have on the topic would be greatly appreciated!
 
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MEAH95 said:
Thank you! Do you have any references that I can use when talking to my superiors about why the provider needs to state the stage?
Click to expand...

It is the provider's job to diagnose patients and document appropriately. If your superiors think that coders can diagnose patients based on lab results, that's a little scary!

I'd be tempted to ask them for sources that it's okay for you to practice medicine without a license (only partially kidding about turning it around on them!). However, if they want to see some sources, they can look at any/all of these links for starters. You could probably find more examples - I just grabbed a few of the first ones I found:


Providers determine the stage of kidney disease using the glomerular filtration rate (GFR), which is a math formula utilizing a person’s age, gender, and serum creatinine level. Coders and clinical documentation improvement specialists should not assign a code for CKD or ESRD by reviewing the patient’s GFR; providers should document the stage and address the GFR to code the final diagnosis.


Screenshot 2024-01-17 172444.png


Screenshot 2024-01-17 172640.png


Above link is a primary care provider's website linked to an Optum handout that states:

Screenshot 2024-01-17 172313.png
 
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MEAH95 said:
We have a bit of a disagreement at my work on interpretation of test results.
An example would be: Patient is seen for CKD, congestive heart failure, hypertension and various other issues. The doctor never states the stage of CKD.
However he does have an estimated GFR in the test results. Is it appropriate to pull the Estimated GFR and give the patient a stage of CKD?
Or should the provider be queried to give their clinical opinion of the patients status?
Any references or resources you have of the topic would be greatly appreciated!
Click to expand...

No. Coders cannot interpret test results and use them in codes. The provider must document the stage.
 
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Hi MEAH95
If the med record documentation for the same day says unspecified knee pain, but the radiologist (who is doctor) states in report the diagnosis is M25. 561 R knee pain you can use this as detailed diagnosis code since results showed which knee was injured...the right as to ensure the correct limb added on claim. However stages of disease must be given by treating provider as mentioned above by True Blue.
Lady T
PS Check out HC Billing journal Marc 2023....discussion on radiology coding
 
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sls314 said:
It is the provider's job to diagnose patients and document appropriately. If your superiors think that coders can diagnose patients based on lab results, that's a little scary!

I'd be tempted to ask them for sources that it's okay for you to practice medicine without a license (only partially kidding about turning it around on them!). However, if they want to see some sources, they can look at any/all of these links for starters. You could probably find more examples - I just grabbed a few of the first ones I found:


Providers determine the stage of kidney disease using the glomerular filtration rate (GFR), which is a math formula utilizing a person’s age, gender, and serum creatinine level. Coders and clinical documentation improvement specialists should not assign a code for CKD or ESRD by reviewing the patient’s GFR; providers should document the stage and address the GFR to code the final diagnosis.


View attachment 6757


View attachment 6758


Above link is a primary care provider's website linked to an Optum handout that states:

View attachment 6756
Click to expand...
Thank you SO much! I appreciate it!
 
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You are talking outpatient, correct? I would always direct folks to the official ICD-10 guidelines first. Then, coding clinic. CMS manual may also be a reference.
I agree with Susan. The provider must be queried.
However, I think Covid was one where a lab report could be used to code positive or negative. So, it is possible there may be exceptions but CKD is not one of them.

These may be older and not "official" but good perspectives:

This has references to official rules specifically coding clinic: https://hiacode.com/blog/education/...ot code,diagnosis from the laboratory results.

ICD-10 guidelines: For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the
final report is available at the time of coding, code any confirmed or definitive diagnosis(es)
documented in the interpretation. Do not code related signs and symptoms as additional
diagnoses.
Please note: This differs from the coding practice in the hospital inpatient setting regarding
abnormal findings on test results.
 
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