Wiki Office Note to support Outpatient Testing Diagnosis

[nicoleml]

Hi. I am a Nurse and CPC. In my current position at a large multi-hospital healthcare system, I work closely with our HIM dept using mostly my clinical background to deal with medical necessity claim issues, primarily outpatient Medicare. I am wondering if we have a prescription for a doppler study with a dx for an unspecified DVT, which does not meet medical necessity, if the physicians office note supports pain in the leg ( a covered dx for a doppler) can the pain in the leg be coded from the MD note if it is scanned to our EHR system? Or are we required to get an amended RX? Essentially, I have been told an office note cannot be used for coding since the note is specific to the MD office encounter and not the outpatient visit. Or is coding from an office visit note for outpatient service based on facility policies? Thank you!

 

[thomas7331]

The ordering physician's office notes and treatment plan are a part of the patient's medical record and it is always permissible for the facility to use this information. It isn't necessary to scan the notes into the facility's records (although it may be helpful to do so to make it easier to identify where the information came from in case there was ever a question). In fact, many facilities have a process to simply contact the physician's office by phone to obtain additional diagnostic information to support billing of ordered tests, and to make a entry in the system documenting the phone call. The one thing that you need to be careful of is that the diagnosis you are assigning is clearly linked in the physician's note to the test that was ordered - it's not permissible to simply 'harvest' diagnosis codes from the patient's history to get the service to clear medical necessity - it needs to be documented that the diagnosis was one that was related to the physician's decision to order the test. And yes, as a best practice, this process should be a part of the facility's written policies and procedures.

At one time, Medicare had all of this explicitly stated in their Claims Processing Manual in the section on diagnostic tests. Unfortunately, a couple of years ago they removed it to make revisions and last I checked they had not yet posted the updated guidelines. But I was involved for many years in outpatient facility coding and drawing from related physician treatment plans has always been a routine and integral part of diagnosis assignment and verification of medical necessity by facilities and payers alike.