Documentation:
81001 or 81003? The Order May Clinch the Auditor's Decision
Published on Sun May 13, 2012
Plus: 2 tactics help keep tech troubles from derailing your coding.To be sure your documentation supports reporting a urinalysis (UA) code, you need to have a signed order for the urinalysis and proof that your practice rendered the service.Here's how these requirements affect the codes discussed in " 81000-81003 Know-How Requires a Closer Look at Urinalysis Methods" in Urology Coding Alert Vol. 14, No. 5:81000, Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy81001, ... automated, with microscopy81002, ... non-automated, without microscopy81003, ... automated, without microscopy.Create a Plan to Ensure Written OrderMedicare has specific requirements for ordering diagnostic tests. But in an office setting, the urologist and nurse are talking constantly, so overlooking the written order is an easy mistake to make, warns Joan Gilhooly, CPC, PCS, CHCC, president of Ohio-based Medical [...]