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Documenting outside provider lab visits

Documenting outside provider lab visits. Clarence Smiley MPH, MT (ASCP). Objective. Delineate procedures for documenting “outside provider” lab orders. Prerequisites. Labs should encourage outside providers to use ICD-9 codes when ordering labs.

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Documenting outside provider lab visits

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  1. Documenting outside provider lab visits Clarence Smiley MPH, MT (ASCP)

  2. Objective • Delineate procedures for documenting “outside provider” lab orders.

  3. Prerequisites • Labs should encourage outside providers to use ICD-9 codes when ordering labs. • You can proceed without a POV, however coders will have to code the visit later to complete visit which creates orphan labs. • Install EHR on lab computers. • Lab personnel may need to be added as providers in RPMS to create visits.

  4. Indian Health Service • Make sure that outside providers are entered as a provider in your site’s RPMS system.

  5. Step 2: Select visit in EHR Step 1: Select patient in EHR

  6. Step 3: Once you click on “visit not selected” tab, a new dialog box opens. Step 4: In the new dialog box, click on “New Visit” tab.

  7. Example of New Visit dialog

  8. Step 5: Select “Lab” as Visit Location. Step 6: Select the phlebotomist in the All Providers box. Click on the OK button. The selected name should now appear in the Visit tab.

  9. Example of provider name appearing in Visit tab

  10. Create the actual visit • Provider • Purpose of Visit (POV) • ICD-9 code • Actual lab order The above items will prevent “orphan labs” in RPMS

  11. Create the visit Click on the “Visit Information” tab.

  12. Click on Purpose of Visit

  13. Click on ICD Pick List tab

  14. Select Laboratory ICD list

  15. Click on Laboratory Procedures Select the Laboratory Procedures box.

  16. “Lab Procedures” ICD code should now appear in Visit Diagnosis box

  17. If provider supplies ICD-9 code, click on “Add” button

  18. POV dialog box appears; type in ICD-9 code and click the search button to the right

  19. Diagnosis lookup box appears with description, click “OK”

  20. To use this ICD-9 code as the POV for the current visit, click “Save”

  21. POV now added to visit

  22. Outside lab orders • Most outside providers supply an ICD-9 code with lab order. • If an ICD-9 code is not provided, lab may have to call outside provider to obtain an ICD-9 code. • Once code is obtained, you can select a POV.

  23. Additional steps to complete visit • Select Primary Provider (lab person) • Select Secondary Provider (outside physician)

  24. Click on Visit tab to select secondary provider.

  25. Select outside provider from list of “All Providers”

  26. Primary Provider highlighted in red • Secondary Provider highlighted in brown • Click OK at the bottom to save changes

  27. This assures that the lab “notification” will be sent to the provider highlighted in brown. • Click “OK”

  28. Visit now complete • Primary Provider (lab person). • Secondary Provider (outside physician). • Visit tab now shows secondary physician who will receive notification. • Lab will now use RPMS roll & scroll to order lab using lab package. • Coding will merge the two visits (EHR & Lab package visits).

  29. Several ways to accomplish • Can use ICD-9 Laboratory pick list. • Can use POV provided by the physician ordering the lab, usually an ICD-9 code.

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