Can any of you point me to the documentation guidelines in either ICD-9 or CMS that specifically says that a coder could not append an ICD-9 code if the laboratory (or other test) results were available (for example, scanned into the chart, or placed in a paper chart), but not necessarily noted/interpreted by the ordering physician within the progress notes? ICD-9 simply states 'it is necessary to determine from the record'.
I don't think I've ever seen language this specific, and I would be reluctant to code a symptom in the presence of a diagnosis (which is clearly described as inappropriate in the ICD-9 guidelines).
After reviewing further.....I want to note that the original poster (OP) is questioning lab results for an office visit, not a service within the actual lab. The results would not arrive in the practice without first having been interpreted by a physican (from the lab). I can't see that it's necessary to have the results re-interpreted by the ordering doc, they simply should be signed/dated by him as having been rec'd. However, when coding at the lab, appending an ICD-9 code without any interpretation at all (for example, results provided by a medical technologist, before the MD provides a report), would be inappropriate. I think people are answering based on a different scenario than our OP questioned.
But if I'm way off base, I would appreciate seeing evidence of documentation guidelines.
Last edited by Pam Brooks; 04-16-2010 at 12:27 PM.
Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
Dover, NH 03820
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