Wiki Provider Documentation for Ancillary Services

[Jody Mortensen]

Hi, I'm under the impression that the provider needs to document the diagnosis/reason for all labs & diagnostic imaging ordered in the patients record. I recently started at a new facility which has an EMR. The provider assigns all diagnosis codes and as an example: will document dx code of V70.0 for a physical exam & then adds documentation that labs were ordered. If the provider orders say a TSH for a Medicare patient & links the diagnosis code to V70.0 & under the patient's chronic history hypothyroidism is listed can a coder assign the dx code of 244.9 to the TSH ordered? I believe a coder cannot, that the dx code of V70.0 would have to be assigned because that is the diagnosis code documented or the provider would need to be queried if the TSH was ordered due to pt having 244.9 & the provider would need to amend the documentation to support?

Would anyone be willing to validate my question/concern & if knowing of a reputable reference that I could check out to show my superiors it would be greatly appreciated.

Thank you Jody Mortensen