Wiki Outpatient Coding Clarification

[kmcafee]

I am new to OP coding. I code outpatient diagnostics. I am to look for the physicians orders and code the diagnosis from it. Sometimes the diagnosis does not meet medical necessity and I have to send a referral to the department for a dx that meets MN. I guess what I am getting at is, If I have a definite diagnosis from say the test result that they ordeered, can't I just code the result? I have been told I must code what is on the order no matter what. Since I have worked in physician's offices in the past, I know that many times they just put evey dx that the patient has just in case. I am confused about the coding guidelines and the physician order. Is there a place in the coding guidlines that addresses this area?

 

[mitchellde]

You code from the providers documentation not just the orders, also if a test has been performed on the same day as the encounter then you may hold the claim for that encounter until the test is interpreted, an outpatient or physician based coder may code from the radiology report or the pathology report even if the ordering provider has not seen the report.

 

[kmcafee]

Thanks Debra for the info!