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Tag Archives: Orders

Orders for Lab tests

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Hi Guys,

My physicians order lab tests routinely for their patients. Most of the time, I see what was ordered at the bottom of their progress note. The problem I’m having is there is no diagnosis information listed for each test. Some of them are self-explanatory like testing A1C for DM but other times it is not clear what the primary reason is for doing the test. My question is, does every lab test order in the EHR need the diagnosis code or the reason why the test is being done? Any help you can provide would be helpful!

Thanks!

Mary

Medical Billing and Coding Forum

Physician orders for laboratory tests

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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?

Medical Billing and Coding Forum

Coding refusals & future orders with annual physical

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Patient is being seen for an annual physical. Z00.00

BUT… they refused the offer of a colonoscopy

AND… the provider is ordering a mammogram.

To include or not to include…. Z53.20 for the refusal AND/OR Z12.31 for the mammogram order.

Discuss. :confused:

Thanx!!

Medical Billing and Coding Forum

Modifying Diagnostic Test Orders

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It is expected that testing facilities will not routinely modify diagnostic test orders from the ordering physician. Although diagnostic test orders may conditionally request an additional diagnostic test, the conditional request must come from the ordering physician. New orders must be obtained when a test is determined to be clinically inappropriate or suboptimal, or when […]
AAPC Knowledge Center

Texting of Patient Orders Not Permissible

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Texting is convenient, but it isn’t always permissible in a healthcare setting. A recent memorandum from the Centers for Medicare & Medicaid Services (CMS) instructs that healthcare providers may not text patient orders to one another, although “texting patient information among members of the health care team is permissible if accomplished through a secure platform.” In […]
AAPC Knowledge Center

Trump Orders Expansion of Healthcare Insurance Options with Cheaper Coverage

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Despite the inability of republicans in Congress to roll back the Affordable Care Act (ACA), President Trump has promised an executive order to offer relief to healthcare consumers facing rising insurance premiums. He is using “the power of the pen,” according to a tweet, to overhaul healthcare. <INSERT TWEET SCREENSHOT> Under the ACA, new insurance requirements prohibited insurers […]
AAPC Knowledge Center

Physician Orders

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Hi,

I have a question concerning the time limit for an order. If a physician submits an order for a patient to come back in a certain amount of time, for example, labwork. The order states for the patient to come back in three months for glyco, comprehensive etc, and the patient doesn’t come back in that allotted time, but comes in a couple of months later. Is that order still good or would the lab need to obtain a new order to do those labs?

Thanks,

Melody Underwood

Medical Billing and Coding Forum

PCP billing for hospice orders

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Hi everyone, I have a question about Hospice patient charges. I work for a PCP, one of our Medicare patients is entering into Hospice. My doctor has written extensive orders for the Hospice company. My question is, can we charge for this. My supervisor wants to know if we can use G0182? If this is not the appropriate code, can anyone help us with the correct code? Thank you

Medical Billing and Coding Forum

Physician Orders for Lab, Radiology Services, and Other Services after ICD-10 Implementation

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CMS is not requiring the ordering provider to rewrite the original order with the appropriate ICD-10 code for lab, radiology services, or any other services after ICD-10 implementation on October 1, 2015, including Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).

Products and services that require a diagnosis code on the order will use ICD-9-CM codes if written prior to October 1, 2015. If the order is for a repetitive service that will continue to be delivered and billed after October 1, 2015, providers have the option to use the General Equivalence Mappings (GEMs) posted on the 2016 ICD-10-CM and GEMs web page to translate the ICD-9-CM codes on the original order into ICD-10-CM diagnosis codes.


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