Wiki Physician orders for laboratory tests

[baroquecoder]

Clinic is stating they placed an order for urinalysis 'digitally' so they don't need to submit documentation for the UA. I'm unable to code it as there is no diagnosis or intent for the procedure indicated. What are the documentation requirements for a physician ordered laboratory test? Shouldn't there be a document in the medical record that corresponds to the 'digital' order?

 

[Birdie625]

Hi, this is an old thread, but I have similar questions. I wanted to ask are the following 'internal' policy questions or 'required by CMS type policy'. I am embarrassed of myself for asking these:
1) IF a provider puts in an e-order, but I don't see a signature OR any dx, but I see on a note prior whereby they mention "xyz test for xyz dx" (the "intent" (to me) was mentioned on the office note on a different DOS when they 'ordered' test) - Is it 'legal' for me to use that dx (from a prior DOS note) (Or is this an internal policy issue)? (and I document everything of where I got what ('i.e. dx from note dated 1/1/2020'), did what and why).
2) Having a difficult time 'policy' wise in organization and I don't want to be involved in any FCA suits.
3) RE: Outside providers (those who do not have access to the EMR and submit paper orders) - I do wait for those orders to be scanned in chart before appending 'their' dx's.
IF I see on paper order by outside provider 3-tests (i.e. CBC, CMP, Vit D), but I see the lab did 5-tests (CBC, CMP, Vit D, Lipid, TSH) - I 'wait' for the other tests order to be scanned in. IF no order for the extra tests done, to me, that is not good. We have no order, no notes, no 'intent' to order and to me that is bad. My thinking is these extra tests (w/o order, note) should be adjusted off before billing (the other tests) to insurance (the hospital/lab 'eats' the extra tests). I tried to read thru some MLN and CMS links, but honestly, I got lost in reading through it. I have no current (internal) instructions on how to handle these situations, but I am not releasing the claim to insurance. In meantime, the other 'legal/documented' tests are also not getting billed. I am attempting to get some manager of sort to answer these questions, but in meantime, here I am.
Question - Am I of right mind to be thinking what I said in # 3 above? Re-reading it, it 'sounds' completely legit thinking. IF a manager says "No, release as-is" I don't want to personally do something that is illegal, just because my 'super' tells me to.
4) and lastly - Outside provider on paper order is for PSA -Diagnostic (84153 w/dx of R97.20)- Lab for some reason (!?) does a PSA - Screening test (G0103). I am working these based on what my 'super' told me to do, but is it even 'correct' to bill a PSA Screen if provider ordered a PSA Diagnostic? Similar to #3 above, it is a different test (apparently the 'same' test lab-work wise (?), but is not CPT/payment wise). I cant wrap my head around this and am afraid I am doing something illegal.
Thank you for your time and consideration in answering these questions. Birdie

 

[karamac]

So let's just talk about what an order is... whether electronic or paper.. per CLIA your laboratory needs to be able to provided documentation (i.e. a printed e-req, or paper req) that supports the testing... no signature on either of those.. guess what we are then stuck with the ordering providers documentation... so you need an order, even when a hospital gets a verbal order they have 30 days to get a written copy of that order. In your number three, if you don't have an order for Lipid and TSH then you can't bill.. if you did then you would be billing 80050 (General Health Panel to Commercial Payers only) + Vit D and 80061. Bill for the tests that you have an order for, you can always submit an amended claim. To be frank, that combination of testing together on one claim is going to trigger a flag at most payers anyway.

My bigger question is .. why would you append a diagnosis code to a laboratory claim when you don't have access to the medical record? You are a lab, you aren't treating the patient and we certainly can't guess as to why a certain test is ordered. Remember each laboratory test can have one or more associated diagnosis codes that are aligned to it. Best rule of thumb for a clinical laboratory-- no diagnosis code- no testing. I think many labs can tend to want to please their providers, but when an audit comes and we don't have a paper trail. Big issues. There are only a handful of tests, with Medicare that have diagnostic code requirements, if it is molecular testing, the lab needs to get the test prior authorized with the payer anyway.

#4-- this is simple, and you are right.. the provider ordered 84153- if the lab performed G0103 even if similar because they reimburse differently it's a no.. you bill for what was ordered and what work was performed. This could be a very simple fix in the laboratory information system.

diagnosis codes, diagnosis coding