Wiki No Diagnosis for Point of Care tests in office

[LuckyLily]

I am seeking some information on what others are doing or what should be done for this situation.

Physician will document for conditions that are addressed such as Neck Pain (M54.2) and Paresthesia (R20.2).
Then a Point of Care test will be done that does not have any diagnosis associated with it. For instance, note will have the two codes given then have a POC Hepatitis C Screen and POC HIV Screen done.

1. for these tests would you only put the M54.2 and R20.2 on these line items. Since this is exactly what the provider signed off on.
2. query the provider for a diagnosis for these tests.
3. coder add the screening codes for these tests.
4. other??

 

[mitchellde]

There does not seem to be any rationale for those specific tests. You indicate an HIV screening test. SO if the provider did write HIV screening then we can code that as a screening but unless specified as a screening then you cannot assume this so either use the codes for the issues as addressed by the provider, or query the provider for an addendum to the document.

 

[LuckyLily]

I agree that there is no rationale between the diagnosis given and the screening tests. What I've been doing is using the diagnosis given and applying them for the tests. It's obvious that one has nothing to do with the other. This would be a good training example for the providers.

Thank you for your reply.

 

[thomas7331]

I'd suggest perhaps sharing with the providers the section from the CMS 1995 Documentation Guidelines for E&M Services, section II, General Principles of Medical Record Documentation. Among other things, it includes the direction that "If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred." If the lab or hospital performing these tests were ever audited, the payers could look to the ordering provider's documentation for the rationale to support these tests, so it is really essential that this be clear in the record.