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Click here for more sample CPC practice exam questions and answers with full rationale

Obtaining Diagnosis Over the Phone

1) Patient receives a bill from the pathology laboratory and contacts his provider. The provider then phones the lab to provide additional diagnosis codes to re-file a claim. Is the lab obligated to obtain a written confirmation of the diagnosis obtained via the phone call?
2) Provider orders laboratory work on a patient but does not provide a diagnosis on the lab order. Can the lab staff phone the provider for a verbal diagnosis if the claim has not yet been processed for adjudication? Is the lab required to obtain a written confirmation of the diagnosis obtained via the phone call or can the lab merely document the additional info/diagnosis onto the patients lab request?

Medical Billing and Coding Forum