Wiki Medical Documentation

[casseciella]

Can anyone assist with where I can find chart documentation for an ICD-10 code, for example I am looking for the criteria that would need to be met in order to bill A04.8

Chart documentation for this code must include: ??

I work at a lab, so I do not have direct access to the patient's records, but I am trying to assist my provider, so any guidance you can provide would be great!

Thank you!

 

[csperoni]

The lab must report the diagnosis provided by the ordering clinician. I did find this reference for you in Chapter 16 of the Medicare Claims Processing manual (italics & bold added by me):
Physicians Reporting Diagnosis Codes When A Diagnostic Test Is Ordered
Section 4317 of the Balanced Budget Act of 1997 provides, with respect to diagnostic laboratory and certain other services, that “if the Secretary (or A/B MAC (A) or (B) of the Secretary) requires the entity furnishing the services to provide diagnostic or other medical information to the entity, the physician or practitioner ordering the service shall provide that information to the entity at the time the service is ordered by the physician or practitioner.” A laboratory or other provider must report on a claim for Medicare payment the diagnostic code(s) furnished by the ordering physician. In the absence of such coding information, the laboratory or other provider may determine the appropriate diagnostic code based on the ordering physician’s narrative diagnostic statement or seek diagnostic information from the ordering physician/practitioner. However, a laboratory or other provider may not report on a claim for Medicare payment a diagnosis code in the absence of physician-supplied diagnostic information supporting such code.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c16.pdf

So, if the ordering physician supplied A04.8, you would bill that. If the ordering physician supplied simply R19.7, that is what you would use. I do know that sometimes as an ordering physician, the lab will contact us to (hopefully) provide a different diagnosis that may justify a test that was ordered. If you are getting claims denied for non-justifying dx, you must contact the ordering physician to see if they can supply a different diagnosis.

 

[casseciella]

Thank you for your response!

I understand that the provider should supply the dx, but long story short, we bill certain CPT codes that are only covered with certain dx codes. Therefore, if I can provide some guidance to the providers to see if they can select A04.8 vs R19.7 (if there documentation supports that) then i would like to do that. So I am just trying to see if there is anywhere to find some type of medical criteria that needs to be meet in order to code a certain dx?

Is there anything like that out there?