Oncology & Hematology Coding Alert

Labs:

36415 Documentation Should Specify Method to Ease Audit Worries

Follow this advice to be sure your EHR isn't setting you up for trouble.Electronic health record (EHR) documentation templates can be a blessing and a curse.Case in point: If your system doesn't prompt clinicians to document the method of a blood-draw, auditors may decide documentation fails to support your code choice for the procedure. Steer clear of this trap with expert insights into the documentation you need and how you can be sure you get it.See How Method Matters for Code ChoiceBefore EHRs (also called EMRs or electronic medical records) took hold, labs typically had a collection log where they would document how and at what site a specimen was drawn. Now, an EHR may provide the information for a venous blood draw. It may neglect, however, to tell you what method was used for the draw.For example, the EHR may show: "Specimen: blood, Drawn: at 1pm, By: Suzie Q [...]
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in Revenue Cycle Insider
  • 6 annual AAPC-approved CEUs
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more

Other Articles in this issue of

Oncology & Hematology Coding Alert

View All