Jholden21
New
We are hoping for some DEFINITIVE RESOURCES TO CITE (coding clinics? some guideline we've missed somehow? for or against!) for this OUTPATIENT LAB coding question. The part that all of us agree on, no questions asked, is we absolutely cannot code off of lab results alone - they need a provider's interpretation documented no matter what. We know that for diagnostic tests (e.g. MRI), the radiologist's interpretation on the report can be used or the pathologist's report from a biopsy can be used to code dxs on the surgery encounter. However, the somewhat gray area is whether or not you can use the ordering provider's written interpretation of the LAB TEST results that are documented after the lab draw DOS to code for said lab.
Example: Provider orders an iron panel because pt complains of fatigue and has restless leg syndrome (RFV for labs). Pt goes back into the office for a quick follow-up two days later to discuss the results of the labs and the provider diagnoses the patient with anemia based off of the labs. Can anemia be used, based on the follow-up OV documentation, as a final diagnosis for the labs themselves?
We've scoured the guidelines and coding clinics to try and find something that definitively states yes or no and surprisingly everything just says something along the lines of "if there is a final report available at the time of coding, which is authenticated by a physician, it may be used to code from." I'd like to say all of our claims are coded within 24 hours but they're not and we typically have the interpreted results in the chart by the time coding is done. We also can't find a guideline that specifically states we can't use that interpretation either. Here are a couple things we've come across related to this but nothing gives a time frame in relation to the DOS or clearly states if there's a difference on how this is done between laboratory tests vs. other diagnostic testing/imaging.
Guidelines: "For outpatient encounters for DIAGNOSTIC TESTS that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses."
Coding Clinic: ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2017 Page: 7 Effective with discharges: March 13, 2017
"Laboratory coding of outpatient CBC test"
Anyone have any input/experience/resources on this? THANK YOU so much for any help!
Example: Provider orders an iron panel because pt complains of fatigue and has restless leg syndrome (RFV for labs). Pt goes back into the office for a quick follow-up two days later to discuss the results of the labs and the provider diagnoses the patient with anemia based off of the labs. Can anemia be used, based on the follow-up OV documentation, as a final diagnosis for the labs themselves?
We've scoured the guidelines and coding clinics to try and find something that definitively states yes or no and surprisingly everything just says something along the lines of "if there is a final report available at the time of coding, which is authenticated by a physician, it may be used to code from." I'd like to say all of our claims are coded within 24 hours but they're not and we typically have the interpreted results in the chart by the time coding is done. We also can't find a guideline that specifically states we can't use that interpretation either. Here are a couple things we've come across related to this but nothing gives a time frame in relation to the DOS or clearly states if there's a difference on how this is done between laboratory tests vs. other diagnostic testing/imaging.
Guidelines: "For outpatient encounters for DIAGNOSTIC TESTS that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses."
Coding Clinic: ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2017 Page: 7 Effective with discharges: March 13, 2017
"Laboratory coding of outpatient CBC test"
Anyone have any input/experience/resources on this? THANK YOU so much for any help!