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Thread: Documentation of labs ordered in progress note.

  1. #1
    Join Date
    Apr 2007

    Default Documentation of labs ordered in progress note.

    AAPC: Back to School
    If a patient has 278.00, 401.9, 250.00, 272.4 and 268.9 and on the bottom of the note in the labs ordered section, the doctor circled are CMP, CBC, A1C, Lipid Profile, Urine microalb/creatinine.

    Would an auditor match each dx to the lab test that was circled at the bottom, or does the doctor have to match them up in his documentation of the visit.

    What is considered "easily discernable" in Medical Documentation? Is a list of dx on assessment, then a list of labs on the progress note acceptable or does he have to tie each test he orders to the specific matching dx in the progress note.
    Heather Winters, CPC, CFPC

  2. #2
    Join Date
    Apr 2007
    Louisville, KY



    What you ask is an interesting puzzle.

    At my facility, coders are expected to match the appropriate diagnoses to each lab exam. As you know--as with CBCs--there can sometimes be multiple diagnoses associated with one, single lab exam. However, the provider's orders (of which the progress note is not likely the official order) should clearly state the reason for the exam. This is not always carried out properly and can make the coders' job that much more tedious.

    Ideally, coders should be able to "easily discern" which labs are ordered for particular diagnoses; also ideally, the providers will concisely record the diagnosis or reason the study is being requested (e.g., medical necessity). Depending on the organization of the facility or practice for which you're working, this may or may not exist in this state. Therefore, confirmation of an abnormal lab value, findings after study, associated signs/symptoms and the order are the coders' best resource for properly linking the codes together. As a last stop, it'd be the progress note, usually in the absence of appropriate or confirmed diagnoses through any of the previously mentioned routes.

    Hope this helps.
    Last edited by kevbshields; 09-16-2009 at 05:57 PM.
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

  3. #3
    Join Date
    Apr 2007

    Default Order

    Thank you for your reply. It does help.

    In our practice, the progress note IS many times the only documentation I have to go by. When the provider circles the labs he wants completed before the next visit on the bottom of the progress note under the plan section, that is my only order. From that order the nurse draws the labs here and sends them out.

    It seems to be a puzzle sometimes to match up the labs we draw with covered documented dx codes from the assessment. I routinely have to review LCD's, NCD's etc trying to match up the codes which can be very timely.

    I was concerned that the note itself does not draw a link between each test and it's dx that supports medical necessity.

    For instance, if an A1C is ordered, but Diabetes was not mentioned in that particular note assessment, I have to go back to the problem list and use the Diabetes code from that source or a previous progress note. Should I really be doing that or should the provider be clearly documenting the relationship between the labs he is ordering and the dx he is trying to treat?
    Heather Winters, CPC, CFPC

  4. #4

    Thumbs down repeat clinical procedures, or codes within panels

    I have recently been working in the field of pathology coding. And find an interesting yet complicated issue of repeat clinical tests for IP care.

    My questions do not involve the Medicare program which is very clear. However, I see challenges in reimbursement by use of a modifier alone to document medical necessity of a repeat test on the same day; and definition of same day - so I would like some opinions on my questions.

    If a duplicate clinical procedure is performed on a patient the same day, but not the same session, i.e. (seen in ER test OK, came back with worsening symptoms) repeated same test in same day - does this support use of modifier 59 for repeat test. Or 91? Is it sufficient to send reports indicating different times, or actual notes from the hospital?

    If a patient receives a General Health Panel, then has 1 test repeated which is in the panel on the same day, for documented medical necessity - can we append a 59 to get reimbursement, and would we be required to provide progress notes, if IP, or corrected claim with just 59.

    ALL questions assuming we are only billing for PC 26.

    IF the hospital is providing the billing charge file and hard codes a 59 or 91, is this appropriate documentation for the physician to add the same modifiers - or should hospital protocol be reviewed annually by the pathology group, and can the hospital act as the employee overseeing the machine, to ensure the test was not redone due to machine failure.

    I realize this is a lot and hope this thread will continue and I may ask additional questions to you experts out there.


  5. #5
    Join Date
    Apr 2007
    Milwaukee WI

    Default Repeat Procedure is Modifier 76

    The correct code for a repeat procedure is 76.

    And please start a new thread if you have a new question. Don't just reply to this thread.

    F Tessa Bartels, CPC, CEMC

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