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Is "INR OK" sufficient documentation?

  1. #1
    Location
    Salt Lake North
    Posts
    691
    Cool Is "INR OK" sufficient documentation?
    Medical Coding Books
    I was told by my office manager that I am too picky about documenting properly.

    A doc wants to bill for doing a Protime and the documentation states: INR OK.

    It does not state that it was done on that date. It does not state the result (like 2.3) anywhere.

    The only documentation is "INR OK"

    I don't beleive that that is properly documented. But am I being too picky like the office manager says?

  2. #2
    Default
    Quote Originally Posted by qcoder View Post
    I was told by my office manager that I am too picky about documenting properly.

    A doc wants to bill for doing a Protime and the documentation states: INR OK.

    It does not state that it was done on that date. It does not state the result (like 2.3) anywhere.

    The only documentation is "INR OK"

    I don't beleive that that is properly documented. But am I being too picky like the office manager says?
    Forgive my ignorance, but what is INR? I'd advise the doctor to be more specific, if possible (avoid uncommon acronyms, when possible) - he wouldn't want to leave information up to an auditor's interpretation, who hasn't been to medical school, would he? And to answer your question I wouldn't count it under the exam. I might count it under the MDM, as long as the location of the results is specified, or they're attached to the chart. He doesn't have to rewrite the lab results, but he should reference them clearly enough in his notes so that their clinical relevance is apparent, to get credit. Per CMS guidelines, the rationale for ordering diagnostic tests should be easily inferred. Hope that helps!

  3. #3
    Default Example
    http://www.trailblazerhealth.com/Pub...9211JobAid.pdf

    Page three gives example and logic for just such a office visit and documentation that is likely to be expected.

  4. Default
    INR is International Normalized Ratio and it tests for bleeding/clotting issues. Normal is acceptable so ok may be as well but the number should be documented for best patient care since the numbers should be tracked.

    Is the provider using a portable/in office test?
    Is the provider 'reading' a lab result actually interpreted at the lab? Is that why the dates don't match?
    Dee
    CPC, CPCO, CPMA, CPCD

  5. #5
    Location
    Salt Lake North
    Posts
    691
    Cool
    Deecoder. It's not that the dates don't match. It's that he does not give a date for the lab in which he is stating that the result is OK. We draw the blood and run the test ourselves. But I think to be properly documented, the doc should state the date that it was done and the actual result and not "INR OK". This test is repeated very, very often. Someone could intrepret that the doc is referring to all the INR lab results as a whole and stating that generally the results are OK.

  6. Default
    I agree, if he does not have a date or indicate that the test wast done at that visit then I wouldn't bill it.

    Sometimes it is hard to know the backround of a question. Our docs do not draw and run most tests.
    Dee
    CPC, CPCO, CPMA, CPCD

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