Wiki Labs and DX

[maryjoanna152]

Physician or NP notes on documentation (that is in the medical record) that at the hospital the patient had an ANC of 800, and therefore qualified for Neupogen, so they were sent back to the office to receive this.
My question is...... is it acceptable to code from the ANC of 800? (which if your ANC drops below 1,000 it is called neutropenia)

Is there some rule that you can not code from a lab result? Are labs not included in what makes up medical record components? Which we code from the medical record?

Any help would be appreciated!
Thanks

 

[mitchellde]

a coder cannot interpret a lab result it must be documented that this is abnormal or elevated or neutropenia etc.

 

[maryjoanna152]

Thank you, Can you please direct me in where to find the guidelines that are stating this?

 

[mitchellde]

let me check I think it is in the coding guidelines but it is also stated in coding clinics. But here is the deal a coder may code only from physician documentation and physician rendered diagnosis, a lab is a reported value that requires written provider interpretation to be coded.