A physician uses an EMR office visit template but also dictates into the EMR. He orders 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, and CBC. ---------- NOW....in his dictated note under the A&P, he lists all the patients diagnosis like this: 1. Diabetes, 2. HTN, 3. Hyperlipidemia 4. GERD 5. COPD, but no where does he state what tests he is ordering for which diagnosis. Are we allowed to "assume" and link each test to the diagnosis given in the A&P 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......2. HTN -- will get a CBC.........3. Hyperlipidemia -- will get a lipid panel ----. I've got some coders saying that the reasons for each test should be easily inferred so we can link the diagnoses given ourself to each test ordered -- BUT others are saying that the physician or the nurse must document what diagnosis goes with each test. PLEASE HELP !!