Wiki waiting until results come back to dx patient and file claim

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amexnikki23

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Is it legal or ethical to wait 1-2 days for lab results to come back before assigning final dx code and filing the claim? Say a patient presents with obesity and wants a referral for nutritional counseling, and the provider runs labs tests to test for any obesity related conditions prior to issuing the referral, and the next day, the lab results return DM type 2, and hyperlipidemia. The provider wants to know since the claim was not filed yet, and her progress notes not yet completed/locked, can she add the DM and hyperlipidemia to the claim, rather than just the obesity (due the chance that the obesity without an obesity related dx may prompt a denial if a non-covered service).
 
the dx or dx's when ordering labs is for known medical conditions that the patient has or for symptoms they are experiencing that would then prompt the dr to order labs. This would be like a dr holding out billing an xray on a leg for a pt that c/o leg pain. The dx on the xray would be leg pain. If the xray shows a fracture, the dr would not then go back and void his claim and rebill it w/ the fx dx.
 
You are allowed to hold the claim to wait for results of tests performed on the same day as the visit. Labs must be physician interpreted so yes as long as he amends the note with the dx code we may hold and bill with the amended note. We do this with skin lesion excisions where we are required to hold the claim for path results. And yes we hold possible fx claims all the time to await the X-ray results. There is absolutely no issue with this.
 
I agree only on excisions and xrays. But holding a claim for bloodwork to then bill the claim based on what the results show is coding a claim to ensure that you are going to get paid either way. What is the lab results were all WNL?
 
You cannot just accept it for X-rays and excisions. Test results are test results and as long as the test was performed the same day as the encounter and a medical professional renders a dx based on those results then it can be coded by the coded for that days note. Labs must have provider interpretation so the coder must wait until the note has been amended with the result. This is not an issue of reimbursement, it is an issue of giving a more accurate picture of the patient condition. If the patient has type 2 diabetes they had it at the encounter it just had not yet been uncovered. There is no regulation that will prohibit this. As long as the coder is basing the codes on physician rendered diagnosis. The dx for this encounter will,still,be the obesity or morbid obesity first listed as that is the reason for this encounter. However the coder may need to query the provider as to whether the diabetes is secondary (249) due to the obesity.
 
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teresabug said:
the dx or dx's when ordering labs is for known medical conditions that the patient has or for symptoms they are experiencing that would then prompt the dr to order labs. This would be like a dr holding out billing an xray on a leg for a pt that c/o leg pain. The dx on the xray would be leg pain. If the xray shows a fracture, the dr would not then go back and void his claim and rebill it w/ the fx dx.
Click to expand...

Thanks, I'm not referring to re-billing a claim, I am talking about the provider getting the results back the next day, and adding them to the encounter (before it even becomes a claim). By the time I create the claim, the results are already in the encounter, so it shows "obesity" as the primary dx, and now it also shows DM and hyperlipidemia, and I assumed it was ok to attach those dx codes to the claim as well, since they are in the encounter.
 
The ICD-9-CM guidelines support reporting of these dx. "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."
 
Cynthia Hughes said:
The ICD-9-CM guidelines support reporting of these dx. "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."
Click to expand...

Cynthia, wouldn't the physician that ordered the test need to amend/update the record to reflect the diagnosis on the lab results THEN the claim be coded/billed?

Lena
 
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