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LAB REVIEW-1pt or 2?

  1. #1
    Default LAB REVIEW-1pt or 2?
    Medical Coding Books
    If a physician dictates the results of labwork that was done while being seen in the ER or in the course of admitting that pt from the ER, does that warrant 1 point for review of labs or 2 points for reviewing and summarizing old records? For example, a patient comes into the ER and lab tests are ordered. In the meantime, the general surgeon is called. By the time he gets there, the tests are finished and he dictates the results into his note and decides to admit the patient. Under data reviewed, does the gen. surgeon get 1 or 2 points? There's a difference of opinion so I'm hoping to gather any insights.
    Thanks for your thoughts-Sue
    Sue Vermette, CPC, CPMA

  2. #2
    Milwaukee WI
    Default Review and/or Order
    Under data points you get 1 point for review and/or order of clinical lab tests.

    Whether you order or review one test or 100 you get just 1 point.

    If you independently visualize an image, tracing or specimen itself you get 2 points. So if the doctor has personally looked at the specimen under the microscope s/he gets 1 point for ordering the test, and 2 points for personally visualizing it and recording his/her findings.

    I would not count your scenario as "review of old records."

    Hope that answers your question.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Makes sense to me. Thanks!
    Sue Vermette, CPC, CPMA

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