Giving credit for labs ordered

[Jenny0831]

when it comes to giving credit for labs ordered, do you give credit only if the tests are mentioned in the progress notes, or can you also give credit if the are not documented in the progress note but ordered in the EHR? Some providers only list a few tests in their progress notes. However, if I look into their orders , I can see multiple labs ordered. Can their receive credit for those? Some of my providers seem to think that as long is in their medical record it doesn't have to be in the progress note.

Does anyone have any insight on this? or are there any specific guideliness to this?

 

[csperoni]

A good EMR system will directly put those lab orders onto the progress note. While I would count all medical records that day and give credit, it is certainly not the best way to organize medical records, leaving too much to be potentially missed. For example, in an insurance audit, it would be very easy to submitted the office note without the separate papers of the orders, As long as the information is in the medical record, you may count it. BEST PRACTICE BY FAR is that the progress note should contain those orders. Same would apply to prescriptions. Some companies may have an internal policy for it to be on the progress note, but I've never seen any CMS or AMA requirement that it must.

 

[Jenny0831]

A good EMR system will directly put those lab orders onto the progress note. While I would count all medical records that day and give credit, it is certainly not the best way to organize medical records, leaving too much to be potentially missed. For example, in an insurance audit, it would be very easy to submitted the office note without the separate papers of the orders, As long as the information is in the medical record, you may count it. BEST PRACTICE BY FAR is that the progress note should contain those orders. Same would apply to prescriptions. Some companies may have an internal policy for it to be on the progress note, but I've never seen any CMS or AMA requirement that it must.I

Hi, thank you for your response.

I was searching CMS and AMA for some specifity if we only count the labs mentioned on the progress note or if we can give them credit as long as they are in the medical record.

 

[csperoni]

You may use all the information in the medical record.
Similarly, if the clinician created 2 notes for 1 visit, you could use both notes. The order must be documented. I am not aware of any guideline that states exactly WHERE it must be documented.