Here is the case scenario: a physician uses an EMR and also dictates into the EMR -- he orders several lab tests by using the EMR template but it does not specify next to each test WHY he is ordering the test. He has ordered a lipid panel, A1C, TSH, Folate, Ferritin, CBC, etc. NOW....in his dictated note under assessment/plan, the MD lists all the patients diagnosis (1. Diabetes, 2. HTN, 3. Hyperlipidemia 4. GERD 5. COPD......etc.), but no where does he state what tests he is ordering for which diagnosis. Are we allowed, as coders, to "assume" and just link each test to the diagnosis that we know is payable??? OR is the Dr. required to state "why" he is ordering each test? (i.e. 1. Diabetes -- will get an A1C, Folate and Ferritin..........2. HTN -- will get a CBC.........3. Hyperlipidemia -- will get a lipid panel ---- etc. etc. etc.
PLEASE HELP !!
PLEASE HELP !!