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Code result or reason for a lab?

AmandaW

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Example:
Dr. orders a TSH for fatigue and hot flashes. Before the patient leaves, the Dr. does dictate the findings of the test. Hypothyroidism was found. The Dr. has hypothyroid in is note but of course did not know the patient was hypothyroid until that test was ordered. I know I could bill hypothyroidism for the E/M, but what about that TSH lab? The reason or the results?

Same for magnesium lab....patient is having muscle cramps. Went to the doc to figure out why. Dr. ordered a magnesium lab, patient is found to have hypomagnesiumemia Dr documented those findings and states "Patient's magnesium lab shows hypomagnesium today" Code the results or reason on the lab charge?
 

btadlock1

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Example:
Dr. orders a TSH for fatigue and hot flashes. Before the patient leaves, the Dr. does dictate the findings of the test. Hypothyroidism was found. The Dr. has hypothyroid in is note but of course did not know the patient was hypothyroid until that test was ordered. I know I could bill hypothyroidism for the E/M, but what about that TSH lab? The reason or the results?

Same for magnesium lab....patient is having muscle cramps. Went to the doc to figure out why. Dr. ordered a magnesium lab, patient is found to have hypomagnesiumemia Dr documented those findings and states "Patient's magnesium lab shows hypomagnesium today" Code the results or reason on the lab charge?
ICD-9 guidelines say that if you have diagnostic tests done, and the results are available at the time the service is coded, you use the definitive diagnosis. You only code the signs and symptoms when you're not sure what's causing them. Hope that helps!;)
 

AmandaW

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Thank you!! That was very short, clear and easy to understand! I don't know why I've been stuck on coding the reason! SO many things to learn! I know we have talked about that before! :)
 

AmandaW

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Brandi, can you tell me what page or around where those guidelines are? I know this is soooo Coding 101, but....?
 

AmandaW

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I don't see an 'L' in my book. It's an Expert book. And don't see on page IV. BUT...on my lunch break I'll look into the guidelines more for it. Thank you for your help!
 

AmandaW

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OK, What if it's something like Radiology. You code the findings of radiology, but what if it was a CT guided biopsy and the pathology is pending on the date of service that you are coding. Can I wait till till those results come back in a couple of days or do I need to just go ahead and code the signs, symptoms (reason for the biopsy) ?

Sounds like the same principle would apply as the lab thing?

The only thing is the transcriptionist will sometimes add the final dx in the note as an addendum when they do find out the final dx. (??)
 

btadlock1

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OK, What if it's something like Radiology. You code the findings of radiology, but what if it was a CT guided biopsy and the pathology is pending on the date of service that you are coding. Can I wait till till those results come back in a couple of days or do I need to just go ahead and code the signs, symptoms (reason for the biopsy) ?

Sounds like the same principle would apply as the lab thing?

The only thing is the transcriptionist will sometimes add the final dx in the note as an addendum when they do find out the final dx. (??)
Any diagnostic procedure - if you're doing it to find a diagnosis, and not to treat a diagnosis, it's a diagnostic procedure. ;)
 

AmandaW

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Right. So, what about the having the results at the time of coding thing? I was just wondering if it would be justifiable to wait for those bx results to come back in 3 days and hold my charge ticket until then and code the result after they enter it into the EMR?
OR go ahead and code the reason for the test b/c at the time of my date of service I don't have results yet.

I'm not the best explainer-sorry! But you see what I'm asking? Basically, to code the reason/symptom/sign OR wait for 3 days to code the result?
 

btadlock1

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Right. So, what about the having the results at the time of coding thing? I was just wondering if it would be justifiable to wait for those bx results to come back in 3 days and hold my charge ticket until then and code the result after they enter it into the EMR?
OR go ahead and code the reason for the test b/c at the time of my date of service I don't have results yet.

I'm not the best explainer-sorry! But you see what I'm asking? Basically, to code the reason/symptom/sign OR wait for 3 days to code the result?
3 days isn't an unreasonable amount of time to wait, especially if the final result will help with medical necessity, but there's no rule that says you have to wait, or that you have to code the visit immediately, so it's going to be up to your doctor. For the sake of accuracy, I'd probably recommend waiting, when possible - especially if it's an unusual or expensive test that will be difficult to get paid. It'll come down to personal preference, though. :)
 
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