Dx on order

cfitzgibbons

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Do providers need to specify dx codes when they provide orders for dme or home care services? I have been told that a dx code does NOT need to be on orders by a manager who is not a coder. I feel that this is incorrect.
 

mitchellde

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Do providers need to specify dx codes when they provide orders for dme or home care services? I have been told that a dx code does NOT need to be on orders by a manager who is not a coder. I feel that this is incorrect.

The code number does not need to be on orders or requisitions for services requested. Th important part is the rendered diagnoses and the service or item requested.
 

cfitzgibbons

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The code number does not need to be on orders or requisitions for services requested. Th important part is the rendered diagnoses and the service or item requested.

So a diagnosis does need to be specified on an order, correct? I don't trust a non coder to code, sorry about that error in my initial post.
 

mitchellde

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The diagnosis does yes but it should not be the code number. It should state diabetes type 1 with mono neuropathy not E10.41.
 
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Non coders changing and adding DX

I work for an anatomic pathology lab. A patient has a GI procedure done for routine purposes, however, polyps were found, now its no longer routine but become diagnostic. My employer has told the collectors to change and or add a routine/screening diagnosis to claims, if the requisition for testing, states routine. This is in order to get max reimbursement. I think that the claims have to be filed with the diagnostic code that the on site pathologist assigns. Wouldn't it be fraud to change the diagnosis by a non certified coder and just to get max reimbursement?
 
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Diagnoses are not required to be on your detailed order, but they must be in the clinical documentation. Most current LCD's give you the list of which elements are required to be on the DWO. At my office we do still have the ICD-10 codes, but they are just for our reference. If you need to access the LCD's just go to your DMAC's webpage.
 
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The diagnosis does yes but it should not be the code number. It should state diabetes type 1 with mono neuropathy not E10.41.

Deb, where can we find the guideline that states the dx should be written out and not use a code written down?
 

mitchellde

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Coding clinics stated this in a manner in 2012. And CMS stated in a couple of transmittitals with regard to ancillary services. Look up orders or requisition for ancillary services. You should find what you seek.
 
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