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Code result or reason for a lab?

  1. Default Code result or reason for a lab?
    Medical Coding Books
    Example:
    Dr. orders a TSH for fatigue and hot flashes. Before the patient leaves, the Dr. does dictate the findings of the test. Hypothyroidism was found. The Dr. has hypothyroid in is note but of course did not know the patient was hypothyroid until that test was ordered. I know I could bill hypothyroidism for the E/M, but what about that TSH lab? The reason or the results?

    Same for magnesium lab....patient is having muscle cramps. Went to the doc to figure out why. Dr. ordered a magnesium lab, patient is found to have hypomagnesiumemia Dr documented those findings and states "Patient's magnesium lab shows hypomagnesium today" Code the results or reason on the lab charge?

    Amanda, CPC
    Urology coder

  2. #2
    Default
    Quote Originally Posted by AmandaW View Post
    Example:
    Dr. orders a TSH for fatigue and hot flashes. Before the patient leaves, the Dr. does dictate the findings of the test. Hypothyroidism was found. The Dr. has hypothyroid in is note but of course did not know the patient was hypothyroid until that test was ordered. I know I could bill hypothyroidism for the E/M, but what about that TSH lab? The reason or the results?

    Same for magnesium lab....patient is having muscle cramps. Went to the doc to figure out why. Dr. ordered a magnesium lab, patient is found to have hypomagnesiumemia Dr documented those findings and states "Patient's magnesium lab shows hypomagnesium today" Code the results or reason on the lab charge?
    ICD-9 guidelines say that if you have diagnostic tests done, and the results are available at the time the service is coded, you use the definitive diagnosis. You only code the signs and symptoms when you're not sure what's causing them. Hope that helps!

  3. Default
    Thank you!! That was very short, clear and easy to understand! I don't know why I've been stuck on coding the reason! SO many things to learn! I know we have talked about that before!

    Amanda, CPC
    Urology coder

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    Brandi, can you tell me what page or around where those guidelines are? I know this is soooo Coding 101, but....?

    Amanda, CPC
    Urology coder

  5. #5
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    Quote Originally Posted by AmandaW View Post
    Brandi, can you tell me what page or around where those guidelines are? I know this is soooo Coding 101, but....?
    They're in the very front of the book, and I believe that the one you're looking for is in Section IV, L.

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    I don't see an 'L' in my book. It's an Expert book. And don't see on page IV. BUT...on my lunch break I'll look into the guidelines more for it. Thank you for your help!

    Amanda, CPC
    Urology coder

  7. #7
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    Quote Originally Posted by AmandaW View Post
    I don't see an 'L' in my book. It's an Expert book. And don't see on page IV. BUT...on my lunch break I'll look into the guidelines more for it. Thank you for your help!
    It's on page 29 on the far right for Ingenix...

  8. Default
    You're awesome.

    Amanda, CPC
    Urology coder

  9. Default
    OK, What if it's something like Radiology. You code the findings of radiology, but what if it was a CT guided biopsy and the pathology is pending on the date of service that you are coding. Can I wait till till those results come back in a couple of days or do I need to just go ahead and code the signs, symptoms (reason for the biopsy) ?

    Sounds like the same principle would apply as the lab thing?

    The only thing is the transcriptionist will sometimes add the final dx in the note as an addendum when they do find out the final dx. (??)

    Amanda, CPC
    Urology coder

  10. #10
    Default
    Quote Originally Posted by AmandaW View Post
    OK, What if it's something like Radiology. You code the findings of radiology, but what if it was a CT guided biopsy and the pathology is pending on the date of service that you are coding. Can I wait till till those results come back in a couple of days or do I need to just go ahead and code the signs, symptoms (reason for the biopsy) ?

    Sounds like the same principle would apply as the lab thing?

    The only thing is the transcriptionist will sometimes add the final dx in the note as an addendum when they do find out the final dx. (??)
    Any diagnostic procedure - if you're doing it to find a diagnosis, and not to treat a diagnosis, it's a diagnostic procedure.

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