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Thread: ICD9 guidelines and lab coding

  1. #1

    Default ICD9 guidelines and lab coding

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    I am debating with myself and I can't find it in the guidelines. It's been a long day.

    If patient presents for an office visit and labs are drawn and processed with results available BEFORE patient leaves that visit, would I rightfully code the reason the lab was ordered or would I code the outcome of the lab?
    (example- pt presents with a sore throat in walk in, so a strep test is ordered, comes back positive)do I code sore throat or strep?I am 99% sure I would not code them both?

  2. #2
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    Default Code results.

    It would better advised to code to the highest level.As this was an E&M visit and you have the results code this with the DX of Streph as I assume you would have the documentation to back it up. HOPE THIS HELPS.

  3. #3
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    You may code the results only if the physician documents the result in the patients progess notes for the visit. A coder is not allowed to code a lab test result without the physician documentation. If you do have the dx documented in the chart then you may code the dx but not the symptom also.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4

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    I'm glad I read this one...I see two different answers - that you can and cannot link lab results. Is there somethink in writing backing up either answer? This is something our hospital coding department has struggled with.

    Penny Young, CPC

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    A lab test is ordered and reported by its clinical indication. There isn't a professional interpretation associated with the strep test code. I would just code the sore throat attached to that procedure code and then the strep diagnosis for the E/M. This is how it played it out over the course of the visit, after all.

    Using strep infection for the strep test would be using the r/o dx to justify the test. Don't do that.

    Assuming the CC is sore throat and the notes indicate the test is performed for that and the results are positive in the assessment with whatever follow-up in the plan.

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    Quote Originally Posted by whaleheadking View Post
    A lab test is ordered and reported by its clinical indication. There isn't a professional interpretation associated with the strep test code. I would just code the sore throat attached to that procedure code and then the strep diagnosis for the E/M. This is how it played it out over the course of the visit, after all.

    Using strep infection for the strep test would be using the r/o dx to justify the test. Don't do that.

    Assuming the CC is sore throat and the notes indicate the test is performed for that and the results are positive in the assessment with whatever follow-up in the plan.
    I am not sure what you saying. But if you are saying that if a strep test has a positive result then the coder can code strep that is incorrect. Only if a provider documents the result as positive strep can the coder then code that dx. A lab result is just that a result with no interpretation. A coder cannot code a dx that has not been rendered by the physician.

    Debra A. Mitchell, MSPH, CPC-H

  7. #7

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    O.k. let me see if I've got this right. I'm coding an ER for the facility side. The CC is sore throat. A strep test is done which comes back postive. The clinical impression is sore throat and the MD/PA doesn't acknowledge the positive test, so I can only code the sore throat.
    If however, the provider says somewhere in his clinical report that the test was positive for strep I can add that to the clinical impression of sore throat and code strep throat.

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    Quote Originally Posted by penyoung View Post
    O.k. let me see if I've got this right. I'm coding an ER for the facility side. The CC is sore throat. A strep test is done which comes back postive. The clinical impression is sore throat and the MD/PA doesn't acknowledge the positive test, so I can only code the sore throat.
    If however, the provider says somewhere in his clinical report that the test was positive for strep I can add that to the clinical impression of sore throat and code strep throat.
    Yes that is exactly correct. But you would not code the strep with the sore throat you would code only the strep if that is what the physician states. You do not need a symptom and the definitive together.

    Debra A. Mitchell, MSPH, CPC-H

  9. #9
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    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).

    Thanks.

    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. Reason: addendum
    Pam Brooks, MHA, CPC, PCS, COC
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  10. #10
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    Not every lab has a physician that provides interpretation of the results. Usually a physician office recieves a report with the results from the machine that ran the specimen. So there is no diagnosis to code until a physician makes an interpretation of the result. Just because a lab test show + strep does not necessarily mean the patient has strep throat. Just because a UA report indicates e-coli is present does the patient have an e-coli infection and so on. The physician usues these results and other factors from his exam and then makes a dx. So when you state you would not code a symptom when a diagnosis is present I agree with you , however when you have a symptom and a recorded lab RESULT with no phsycian interpretation then there is no documented diagnosis only documented symptoms. A coder may only code physician rendered dx.

    Debra A. Mitchell, MSPH, CPC-H

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