Wiki Signing off

[MLH614]

I can't find any guidelines on this. Should providers wait for lab results before closing/signing off on the encounter?

Example: If they order a Vit D lab because the patient is experiencing fatigue. The lab result comes back with a vit D deficiency. Does the provider change the fatigue diagnosis code to Vit D defitiency and then sign off? Or does the provider sign off once they've ordered the lab and then create an addendum to add the Vit D deficiency?

Once it's signed off it will be billed so it would be billed without the appropriate diagnosis if they sign off before the results arrive.

 

[thomas7331]

Either way is correct - it's really up to the provider. But I agree with the post above that if the patient delays or doesn't end up getting the labs done, then the provider has to be holding notes open for results that may or may not come in and if doing this for multiple patients, it could end up creating extra work in follow-up and possible claim delays. It's generally most efficient if the provider can wrap up and bill the encounter note and just deal with the lab results as they come in - that's what all practices I've worked with will do.

Fatigue is not an inappropriate diagnosis if that was the assessment at the time of the encounter and it's perfectly fine to bill it this way. The only potential problem is if the provider billed a diagnosis that the labs later proved was ruled out or incorrect. In that situation you would need a corrected claim. But reporting the symptom for something that gets a more definitive diagnosis later on would not require a correction since the initial encounter was reported correctly.

 

[bgrasson]

they should sign off when the encounter is done- the patient is not guaranteed to go get the labs done- at the lab review visit the provider can go over the results