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Wiki coding lab orders

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mcastold

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What's your opinion? We know the ICD9 coding on lab orders must come from the ordering provider, and there's clear direction & understanding about how to handle orders without diagnosis information (request the information from the provider)....and how to handle orders with 'narrative' diagnosis information (trained lab staff can 'translate' the narrative to the most appropriate numeric code).

However, if the provider supplies an ICD9 code that missing 4th or 5th digit specificity, can the lab 'translate' the numeric code and assign the 'unspecified' 4th/5th digit?

For example, if the doctor writes "hematuria" on the lab order, trained lab personnel can translate "hematuria" to the most appropriate ICD9 code - 599.70 (Hematuria, unspecified). But if the doctor writes "599.7" on the lab order, can the lab also translate '599.7' to the highest level of specificity required for that code set? It seems appropriate to translate to 'unspecified' 599.70'...(and inappropriate to translate to 599.71=gross hematuria, or 599.72=microscopic hematuria).

So...appropriate or not? I appreciate any feedback.
 
you cannot "interpret" a diagnosis from an incomplete code. without the encounter note, the order goes back to the provider for clarification.
 
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