Pathology/Lab Coding Alert

Question: When we receive an order for a lab test, do we need an ICD-9 code from the ordering physician, or can we assign the ICD-9 code ourselves based on the medical record?

Tennessee Subscriber

Answer: The ordering physician should provide either ICD-9 code(s) or a narrative diagnosis to demonstrate medical necessity for a test. If the physician submits an ICD-9 code, you cannot alter the code without getting documentation from the physician to allow the change.

You can, however, assign an ICD-9 code based on a narrative diagnosis, even if the narrative does not exactly match the code descriptor.

If you think that you dont have adequate documentation of a payable diagnosis for a test, you should get the patient to sign an advance beneficiary notice (ABN).That way, you can bill the patient if Medicare fails to pay.

Caveat: CMS encourages, but doesnt require, the physician to provide medical necessity information to the lab. Although CMS will request missing documentation from the ordering physician, the lab still stands to face a denial if the physician fails to comply.