Wiki Screening vs diagnostic lab for potassium

[tag60]

I'm having trouble deciding if this is a screening lab or a diagnostic one because the patient is new.

New pt, never seen at this facility, presents to have potassium level checked. States he had a low potassium result at another facility and needs to have it rechecked, along with a clearance letter for a lifeguard job.

Plan: Recheck potassium level.
Medical clearance letter completed.
Will call with results and treat accordingly if necessary.

Provider gives dx as 276.8, hypopotassemia, and orders lab 84132.

I know I've been told just to go with what the provider states as the diagnosis, but I want to make sure.

Also, IF this were a screening lab, can anyone suggest the screening code to check potassium level? I've looked everywhere and can't come up with an answer.

Thanks so much. I appreciate the help I get on this board!!

 

[mitchellde]

Did the provider actually document the dx of hypopotassemia in the chart note, or does the note state an abnormal lab and he assigned the code 276.8? I have never had a provider diagnose a patient with a condition based on the patient statement of a lab result. So my first thought is that this should be coded as an abnormal lab code and it is diagnostic. But check the note to see if this is a rendered diagnosis or just a bad choice of a code.

 

[tag60]

Hi Debra, the provider stated there was an abnormal lab per patient's statement, and then the provider gave the diagnosis as 276.8 under the A/P portion of the SOAP note (without results of the lab he ordered during the visit). I pretty much gave the note as it appeared; it was a very short one.

Subjective: Pt states he had a low potassium result at another facility and needs to have it rechecked. He needs a clearance letter for a lifeguard job.
Exam: VSS. NAD.
Assessment: 276.8, hypopotassemia.
Plan: Recheck potassium level.
Medical clearance letter completed.
Will call with results and treat accordingly if necessary.

I think this is sloppy/poor documentation, but I have a few providers who code based on suspicion or thinking they need a medical condition as the reason for the lab. Plus this provider gives the clearance letter although he has no lab results from this visit. He has just ordered the lab.

I will take a look when I get back to work and see if the lab was done and if it was abnormal. I guess if it was abnormal, I can code the 276.8...?? BUT if it is normal, what should I use for the reason for ordering the lab? (I don't see that I can code as abnormal lab if the lab was ordered during the visit and the results were not available at that time.)

I'm also wondering how to handle the "clearance letter." Can I use this as the reason for the lab...perhaps V70.3? Or V72.62? (Or do those V codes need an actual physical exam?)

Thanks, once again, for any input!