Wiki Lab order

[Sarah Ann]

A pt. comes in for knee pain- In the HPI, exam, assessment/plan there is only documentation related to the knee pain. Denial for a covid 19 test because the Z code was missing. It was missing because there was no mention anywhere in the encounter HPI, exam, MDM assessment/plan that they were doing a covid 19 test. There is a separate tab for the DOS to look at orders There was an order for the covid 19 only. Does that suffice as documentation? I would think that info. would need to be in the assessment/plan OR somewhere in the note on that DOS. Opinions??

 

[Pam Warren]

From a strictly billing perspective, unless you reported the diagnosis code for the Covid test as part of the E&M visit, there would be no need for that to be documented in the note, since you report the diag only if addressed. Since the Covid test is being performed as a separate billable charge, the diag on the order is sufficient.

However, from a patient care perspective, it is best practice to mention the reason for the Covid test. Exposure? Symptoms? It's always a good idea for providers to indicate why they've ordered a particular diagnostic test somewhere in their note in case there's an issue or concern later on.