SWsibemom
Networker
We use a pathology requisition that has a place for a diagnosis and a place for the provider to add pertinent clinical information/indications/history. The problem we are having is that the ordering provider will fill out the clinical information and not provide a diagnosis in the Dx space provided. When we call the ordering provider, most of the time they state that the Dx was provided in the clinical information or send a fax with the Dx, which usually is the same as what was listed in the clinical information. There are very few instances that the Dx ends up being different than what was provided in the clinical information.
If there isn’t a diagnosis to pick up from the path report, can we code from the clinical information provided on the requisition when a diagnosis was not provided in the Dx area of the form without contacting the ordering provider’s office?
I appreciate any guidance given.
If there isn’t a diagnosis to pick up from the path report, can we code from the clinical information provided on the requisition when a diagnosis was not provided in the Dx area of the form without contacting the ordering provider’s office?
I appreciate any guidance given.