Stefanie
Networker
In October 2010 we initiated our own laboratory. Since then I have been trying to get the providers to sign off on the orders/requistions to support medical necessity for lab tests. Currently we see a note from the nurse stating what labs were drawn and the diagnosis, but the provider doesn't sign the note. I know Medicare states an order nor a requisition form needs to be signed as long as the medical record (i.e. progress note) clearly states the intent of the labs ordered. My question is...would a progress note dated AFTER (a couple of days to a couple of weeks) the labs are drawn considered a supporting medical record for the labs? Also, what if the nurse note says V70.0 and lists all the labs and then the provider note doesn't indicate V70.0 but the note doesn't indicate specifically what the labs were for but the note states the results and the patient has hyperlipidemia, hypertension etc., but the note doesn't link the diagnoses with the labs? Anyone's input is very much appreciated. I have volumes of labs holding until I am comfortable with using the providers medical record to code.