Wiki Regulations on where in the chart we can draw information

[kimberagame]

I work in a private physician's office. Coding has always had the rule of thumb that only information documented in the physician's note or in coinciding chart documents (additional orders notes or quick notes with additional information) can be used on a claim for that DOS. With COVID-19, when we provide a COVID test, we're needing to know the results of that test in order to use the codes requested for that type of an encounter (COVID ruled out or positive COVID). We're wanting to use these whenever possible in order to indicate the insurer should waive cost sharing, and because we've found some straight up saying the codes are required for any COVID related visit. So billing with signs/symptoms, like we normally would before test results are known, needs to be avoided.

So my question - Our providers always document test results in orders tracking. Can we use this documentation to then add the appropriate COVID code to the claim, even though the progress note that we're documenting from does not indicate the test results? Or do we need to task the provider each time to add the result to their note before we can use it?

Thanks for any insights!

 

[thomas7331]

Coding a diagnosis always requires a physician/provider statement that the condition exists - you cannot code from automated lab results. It does not matter where in the chart the provider documents the diagnosis (e.g. the provider may make a notation on the order or on the lab report), as long as there is a documented statement by the provider in the patient's record that the condition was present at the time of the encounter.

As per the ICD-10 guidelines:
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

 

[kimberagame]

Thank you very much for the reply. Yes, we know we can't code from automated test results. I just wasn't sure if we could code from remarks the provider made within orders tracking when reviewing those test results. It sounds like we can as long they clearly indicate the presence or absence of the condition they're referring to. That's very helpful. Thanks again!

 

[ELBrock]

I had a similar question. When a test result is posted in the patient's chart, the provider often makes a comment, (called a Phone Note in our EMR), off the results and sends an electronic message to the MA via the EMR to call the patient with the results. (For example: Bacterial Vaginosis or Candidiasis). We have been instructed from leadership NOT to code from these comments in the EMR, as they are not part of the auditors files and so not reviewed.