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Diagnosis coding for lab only visits

  1. Default Diagnosis coding for lab only visits
    Medical Coding Books
    We are having a lot of discussion on whether it is appropriate for a coder to review past encounters for lab orders for a diagnosis. With our system the encounters do not link when a patient is seen in the clinic and later returns for lab draws, returning testing fluids, etc. Is it appropriate for a coder to search back for the encounter that the labs were ordered in to be able to append a diagnosis for the lab only visit? Is there a guideline for this practice? Any thoughts, suggestions, or concrete eveidence would be greatly appreciated.

  2. Default
    I know we probably have radically different systems, but for us (using RPMS), the provider is required to enter the lab under the order tab (otherwise the lab tech at our facility is required to refuse the lab draw), and the order cannot be completed unless the reason for the lab is indicated

    I would check your "order tab" in whatever EHR you are using, and if it's not there, maybe it's an IT issue

    I think you would also be OK in searching previous visits to see if the provider listed the planned lab in his "plan" section - the Dx may also be there - but obviously, this step is dependent on how well your providers chart

  3. #3
    Location
    Northeast Kansas Chapter
    Posts
    19
    Default Labs done without a currect diagnosis
    In my experience, labs are not covered by insurance without an order and lab orders should always include a diagnosis. I do not think I would ever go back to a previous lab and assume that the current lab is done for the same reason. If there is no diagnosis listed, I'd either call or query the ordering physician for a diagnosis. Sharon Rohlmeier

  4. #4
    Default
    Quote Originally Posted by srohlmeier View Post
    In my experience, labs are not covered by insurance without an order and lab orders should always include a diagnosis. I do not think I would ever go back to a previous lab and assume that the current lab is done for the same reason. If there is no diagnosis listed, I'd either call or query the ordering physician for a diagnosis. Sharon Rohlmeier
    Agreed!
    Walker Bachman, CPC, CPPM

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