Changing diagnosis on denied lab tests

LydiaG

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Any help would be greatly appreciated. If a patient is seen and the provider orders 4 lab tests and documents 2 diagnosis for the visit. Lets say 2 of the labs pay and 2 deny due to non covered diagnosis. If the patient was previously seen (say with in the previous 30 days) and there is a documented diagnosis in the chart for a diagnosis that would be payable for the denied labs, can we change / add the previous diagnosis to the denied labs? This is the current policy in my office however I am having a difficult time finding documentation to support or not support this practice.
 

thomas7331

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The diagnosis code you submit for a lab or any other diagnostic test should reflect the diagnosis provided by the physician or NPP that reflects the reason for the test or the condition that the physician is managing for which he or she requires this diagnostic information. The CFR states "All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary."

If a missing or incorrect diagnosis was provided with the order, the CMS guidelines do state that it would be appropriate to review the record and the provider's narrative to determine the reason for the test. But, simply pulling a diagnosis out of the patient's history without documentation that supports that this was the diagnosis or condition that was the intended reason for the test would not be correct and I think could potentially put you at risk in an audit. This is discussed in various places in CMS publications - if you do some searches on the CMS site for coding and reporting of diagnostic and laboratory services, you'll find additional information.
 

wileym

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@thomas7331 I have tried to search for this on CMS website and I cannot find anything that says there or in CMS publications that it would be appropriate to review the record or the provider narrative to determine the reason for the test. Can you provide me a link to the articles that you are referring to, please? Thank you!
 

Pam Brooks

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We allow the physician to provide a revised/updated order if the diagnosis is non-covered, but only if a covered diagnosis is supported within that patient's chart.
 

thomas7331

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@thomas7331 I have tried to search for this on CMS website and I cannot find anything that says there or in CMS publications that it would be appropriate to review the record or the provider narrative to determine the reason for the test. Can you provide me a link to the articles that you are referring to, please? Thank you!
This CMS guidance used to be located in the chapter on diagnostic testing in the Medicare Claims Processing Manual. Unfortunately some time after the implementation of ICD-10, CMS removed this section from the Manual, presumably because it contained references to ICD-9, and I have not seen that it has been replaced with an updated version. But you can still find the original guidance by searching the archives, which can be a little challenging. Here is a link to one of the earlier publications that contained this - you can find it starting on page 5 in the text highlighted in red:

 
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