Wiki coding From a Lab report

[jennifer.miller1899@live.com]

Hello,

I work in a Lab and there is a Dr. on the staff. Is it ok to code from the Lab report results? Example- you see that they have low Vit D can you code E55.9 from the results. I originally thought no you could not. The billing company said that since there is a Dr on staff that you can. I posted this question in another group and the majority of people said no you can not but some said yes you can. The mixed response confused me even more. Is this a gray area? Does anyone know for sure, or should I do the ask an expert? I have never don't that before.

Thank you

 

[CodingKing]

Anyone who said that you can is wrong. Though this link mostly refers to inpatient many of the concepts apply outpatient as well. Even if the doc signs the lab report you cant code from it.

http://www.fortherecordmag.com/archives/121911p31.shtml

A value reported either lower or higher than the normal range does not necessarily indicate a disorder. Many factors may influence the value of a lab study. These include the method used to obtain the sample (eg, a constricting tourniquet left in place for more than one minute prior to collecting the sample will cause an elevated hematocrit and potassium level), the collection device, the method used to transport the sample to the lab, the calibration of the machine that reads the values, and the condition of the patient. An example is a patient who, because of dehydration, may show an elevated hemoglobin level due to increased blood viscosity.

 

[karamac]

Coding from Lab Report

Agreed! You should not diagnosis code from a lab report. There are way too many variables, and since as coders we don't treat the patient- you amending that diagnosis code that may actually trigger a payment is a pretty big compliance risk. As an example that Vitamin D deficiency could be caused by a gastrointestinal condition such as cealiac disease which could be the primary diagnosis code. Another example - a patient's TSH is high- how do we know if the patient is hypothyroid or if the patient has/or may have Graves's disease?

It's tricky, the best practice is to query the ordering provider in writing and have them document the correct diagnosis code- via an amendment to the chart, and to the requisition.