Missing Diagnosis Code

[CompBeth]

Hello--when a diagnosis code is missing from an order, is it okay to call the physician's office and obtain the code over the phone, or does it require a fax? Can a lab tech or registrar accept the code over the phone, or does it take a clinician? Thanks!

[Deny Morlino]

Phlebotomy checks for the appropriate diagnosis code here. If there is not a code provided by the physician to cover the testing ordered, a process is in place explaining to the patient their options as follows:

1. Refuse to have the test performed

2. Have the specimen collected with the provision that the lab's office staff will make attempts to contact the physician's office to try to obtain an additional diagnosis code that would cover the testing ordered. The patient can choose to have the testing performed only if a proper diagnosis is obtained, or performed regardless of the outcome of the lab staff's attempts.

The additional diagnosis code is entered into the LIS as a free text comment attached to the order, and testing is either completed or not as the patient has chosen. The techs do not have any direct part in this process. This is handled strictly at the office staff / phlebotomy level here. We have had this process in place for several years now with very few missed diagnosis issues on the billing side of the process. All of the offices here are familiar with the daily (or more often) phone calls to resolve these issues. It is not a perfect system, but it is better than missing reimbursement for testing provided. Hope this helps.

[CompBeth]

If the lab receives and order containing an invalid diagnosis, i.e. with symbols indicating 'below' or 'above', or words like 'rule-out' or 'probable'...will the lab be okay in calling the physician's office and writing down what he says, or does a change in the code demand a physician's signature?

Thanks!

[Deny Morlino]

We do not require a physicians signature for a "clarification" such as you describe. Everything is documented in our LIS for future reference if neeed.

[CompBeth]

The other question is, can the registrars or office staff at the hospital or clinic call to obtain the missing diagnosis, or does it have to be lab techs or other clinical personnel?

[Deny Morlino]

That I know of there is not any sort of stipulation restricting the "job classification" . Here it just happens to fall to the lab office personnel. In a dream world, all of this would be handled by the registration staff and be sorted out prior to reaching phlebotomy.

[Malcolm Needs ☆]

In a dream world, the blank, blank doctors would get the request correct in the first place!!!!!!!!!!!!!!!!!!

[Deny Morlino]

If you plan on dreaming, then dream big!!