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Can interpret lab findings or have to have wording?

  1. Default Can interpret lab findings or have to have wording?
    Medical Coding Books
    Sometimes the clinicians will put in a return order or nurse note stating 'Give Neupogen for ANC<1,000 ....something like that...does the wording 'Neutropenia' have to be in there for me to bill out the 288.00 or does the lab results themselves justify dx's?

    Another example, the word 'anemia' not in documentation, but anemia labs were ordered and the pt's HGB and HCT are low....can I bill out 285.9 or does it have to have the word in documentation?

    Amanda, CPC
    Urology coder

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default You can only code what is stated as diagnosis
    Coders are not clinicians (even those with an RN degree) ... It is up to the clinician to record his/her findings/diagnosis. Giving a lab value is not the same ... the coder cannot interpret the lab value, only the clinician can do that.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. Default
    So, if they obviously have a low White blood cell count-Neutrophils....as the coder I can not bill out neutropenia-obvious ones like that?

    Thank you, and JUST clarifying.

    Amanda, CPC
    Urology coder

  4. Default
    ....not from a note (in this example) but from the actual lab results themselves?

    Amanda, CPC
    Urology coder

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default NO
    The coder is NOT a clinician and cannot interpret lab results, whether they are in the lab report or repeated in the doctor's note.

    If the doctor does not state "neutropenia" then the coder cannot code it.


    F Tessa Bartels, CPC, CEMC

  6. Default
    Thank you! This is what I thought. I AM smart enough to see that the 'whatever' is low or elevated, etc. but I wasn't sure if I could code from that. I've heard the nurses and docs say that they can "justify" certain tests and stuff b/c of the results and that the tests results speak for themselves. I agree that I am not the nurse although I CAN read a test result (when the range is in the lab report) BUT that should not be MY responsibility to interpret dx's!!!

    Amanda, CPC
    Urology coder

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