Wiki Coding in EMR...

[warrenfamily103@gmail.com]

Hi,

I have a question that might sound a bit silly but I am used to paper charts and we recently started using some aspects of EMR such as sending labs orders out electronically. My question is this... when I look in the progress note in the EMR, it will show the diagnoses the lab tech ordered as part of the venipuncture. This doesn't always match up with what the doctor documented on the face to face in the paper chart for the same DOS. How should this be handled? Should those diagnoses be deleted from the claim in EMR or should the doctor be queried to add those to their assessment if they were part of a face to face? Prior to EMR, when the lab tech sent out lab orders, I didn't see those because we were not electronic but now that I do, I am confused. I want to make sure we are following guidelines in case of an audit.

 

[Kristen Bensel]

Not silly at all!
However, I had to re-read your question a couple times to make sure I fully understood your question.
If I am understanding your question correctly- the phlebotomist puts a claim in the EMR for the venipuncture and uses a dx that is not the same as indicated in the providers notes for the tests?

The venipuncture is being done because the provider wants a labs done for a specific condition/symptom. I would use the diagnosis the provider used in the note that the order(s) came from- since the provider documented the need for the labs in the plan.

I am curious though, does your EMR possibly auto assign a generic DX to the phlebotomy services because you don't run the labs in house? Is the phlebotomist being directed from someone else to use a generic term like "laboratory test" for their services?