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Lab orders - please help !!

  1. #1
    Question Lab orders - please help !!
    Medical Coding Books
    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. ---------- 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 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 !!

  2. #2
    I am going to lean towards having the dr or nurse let you know which diagnosis goes with which lab. It would make me nervous to just assume the diagnosis. I know, like you said, some are obvious like the A1C. I am surprised there are no diagnosis codes on the lab order in EMR. Is the lab order sent with the blood to the lab? Wouldn't it need to have the dx with it so that the lab could bill it? Maybe your office and EMR is set up differently than mine is.

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