Wiki Counting Unique Order When Pt Forgot Labs

[bdennis]

I'm looking for supporting documentation for: The patient was seen today. They did not get the labs done that the provider ordered at the previous visit. The provider re-evaluated the need for the labs and wants them completed. He educated the patient on the need for these labs. Can I count the order of unique tests again at this visit?
Thank you for your help!

 

[thomas7331]

Given that the provider re-evaluated the patient's need for the labs, and didn't simply write a duplicate order without additional thought, I would count them as a new order.

I don't think you're going to find supporting documentation for this as it's an unusual situation. If guidelines were written for every possible E&M scenario that could come up, those guidelines would be so voluminous that we wouldn't be able to find what we needed anyway. There's always going to be judgment calls required when looking at E&M documentation because every patient situation is unique.

 

[csperoni]

Agree (as usual) with @thomas7331 here.
If it was just the patient had a follow up in 2 weeks & the provider simply reminded the patient the labwork is needed, I would not count that. If the provider re-evaluated the patient and determined even though problem is stable/worsening/improving, that the labs are needed, then that is fair game.

 

[teresabug]

if the provider gave himself one point at the original appt for "ordering of a test" and the patient didn't get the test done, then the provider re-ordered the lab, he CANNOT get credit again in data; he already got credit at the original order. This is considered double dipping. There are FAQ articles that are in the HBM magazines from Rae Jiminez and this question gets asked and answered alot by the AAPC.