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Thread: lab documentation requirements

  1. #1

    Question lab documentation requirements

    AAPC: Back to School
    The question has been asked if the physician must dictate in his report the results of lab tests being done in the office, or if the sheet with the results is enough to bill for the codes 85610 and 80047? They are done by the nurse or other auxillary personel and the results are placed in the patient's chart. Can anyone tell me if this is considered proper documentation for these codes?
    Thank you

  2. #2
    Join Date
    Apr 2007
    Louisville, KY


    For the lab charges, the results are sufficient, as long as they are present in the chart.
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

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