Pathology/Lab Coding Alert

Use CMS Guidelines for Proper Documentation

The Centers for Medicare & Medicaid Services (CMS) stresses that a valid claim must have sufficient documentation to verify services performed were “reasonable and necessary,” and “supports the level of service” billed.

CMS dictates medical record notes should meet the following criteria:

1. Notes are complete and legible.

2. Notes include:

o Reason for the encounter, relevant history, findings, diagnostic test results and date of service;

o Assessment, clinical impression or diagnosis;

o Plan of care; and

o Date and legible identity of the observer.

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

4. Past and present diagnoses are accessible to the treating and/ or consulting provider.

5. Appropriate health risk factors are identified.

6. The patient’s progress, response to and changes in treatment, and revision of diagnosis are documented.

7. The treatment and diagnosis codes (as well as the level of care) reported are supported by the documentation.

(Source: www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf)

Keep These Questions in Mind for Medical Record Analysis

The quality of the provider’s documentation allows coders to not only code with accuracy, but also to the highest specificity.

Tool: Here’s a handy way to assess the quality of the medical record. “When I’m analyzing a record, I like to use the acronym M.E.A.T., which stands for Monitor/Manage, Evaluate, Assess/ Address, and Treat,” explains Keisha Wilson, CCS, CPC, SPMA, CRC, CPB, AAPC Approved Instructor, at KW Advanced Consulting LLC in Brooklyn, New York.

For most laboratory and pathology procedures, the core of the documentation focuses on the center of the M.E.A.T. acronym: Evaluate and Assess. Ask yourself questions such as the following:

What lab test does the clinician order?

Does the clinician document medical necessity for the test?

• What lab method does the laboratory use (different methods for the same analyte often have different CPT^® codes)?
• For pathology services, are the specimen(s) clearly identified?
• Are any ancillary services documented?
• If there are multiple lab or pathology procedures documented, are there any bundling rules you should consider?

Know When You Need to Query Providers

Whenever there is inconsistent, missing, unclear, or illegible documentation, you’ll need to query the provider. To avoid unnecessary or incomplete queries that create more questions, read over the record carefully and look for gaps in the documentation relating to the following:

• Reason/intent for tests and/or procedures
• Ordering and final diagnoses
• Units of service for various lab and pathology procedures
• Lab method details, such as “manual” or “computer assisted”
• Whether test results are qualitative or quantitative

Coding alert: When cross-referencing diagnosis codes, remember to look out for Use Additional notes. If additional information is required to report a code, that may be something you’ll need to include in your query. This is especially true for clinical labs, because the ordering clinician assigns the ordering diagnosis, but the lab relies on the diagnosis to demonstrate medical necessity.

Address a Provider Like This

There are fundamentally three types of queries. A coder can decide which of the following types of queries to use depending on the situation:

• Y/N query: The query is written so that the only answer can be “yes” or “no,” and it does not prompt another question.
• Multiple-choice query: This question includes clinically significant and reasonable options as supported by clinical indicators in the record — understand though, at times, there may be only one reasonable option.
• Open-ended query: This query allows a written response. Use when there are clinical indicators in the notes for a diagnosis, but a diagnosis is not noted.

Always use a consistent, compliant format, no matter which type of query is used. “Keep queries short and sweet and almost emotionless in tone. Don’t lead your providers to an answer either, as that won’t stand up in an audit,” says Kelly Shew, RHIA, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, Risk Adjustment Education Specialist at Olympia Medical in Livonia, Michigan.

Do this: Remember to document your queries and the provider’s response in the patient’s record in case anyone needs to reference the file later.

EMRs: Your practice may have query templates built into the electronic medical record (EMR) that can help you manage and maintain queries. If it looks like these templates have not been activated, reach out to the vendor. If an electronic query management system is not available, you can always create a standard text document to use and store queries.

For more information on queries, check out the AAPC blog: www.aapc.com/blog/85344-take-your-provider-queries-to-the-next-level/.