Orders for Lab tests

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Hi Guys,

My physicians order lab tests routinely for their patients. Most of the time, I see what was ordered at the bottom of their progress note. The problem I'm having is there is no diagnosis information listed for each test. Some of them are self-explanatory like testing A1C for DM but other times it is not clear what the primary reason is for doing the test. My question is, does every lab test order in the EHR need the diagnosis code or the reason why the test is being done? Any help you can provide would be helpful!

Thanks!

Mary
 

Chelle-Lynn

True Blue
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Modesto, CA
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From a documentation point of view all orders should list the reason for the additional testing. While it does not require a specific link to a diagnosis code in the EMR, the intent/reason for the test should be clear. This is a basic expectation for medical documentation by CMS.

If your provider is not currently meeting this expectation then this would be a great opportunity to review the link below from CMS in regards to this requirement. It is always awesome when we have a chance to work with our providers towards an easy resolution. :eek:




Link:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/LabServices-ICN909221-Text-Only.pdf
 
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