RMC’s AHIMA Approved ICD-10 Trainers meet multiple times per week fielding questions from clients and staff.  Below is an actual question that was submitted, along with our team’s response.*

CODING QUESTION:

Dear Sir,
I would like to know If physician has added in assessment Hb-9g/dl or lipid high, as coders can we code it as anemia or hyperlipidemia. As per my knowledge coders are not supposed to interpret the lab values. I couldn’t  find any reference to show the physician stating that coder should not interpret the lab values. Is there any coding clinic on this. I think there is one in 1999 coding clinic but couldn’t download. Could you please help me on this. Awaiting your soonest reply.

RMC’S RESPONSE:

You are correct, coders are not to interpret lab values for diagnoses, this requires a physician’s diagnosis for correct coding.

Referencing: 

  • CC 4th quarter 2015 pages 20-21.  AND CC 2017 1st quarter pgs. 4-7.
  • OCG Section 3 Reporting Additional Diagnoses-
    Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.

Facility-specific coding guidelines
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2014 Pages: 15-16 Effective with discharges: March 31, 2014


Let us know your thoughts! We want YOU to join the conversation! Submit YOUR questions at codingquestions@rmcinc.org

*Every effort has been made to answer these questions to the best of RMC’s abilities, at the time the original question was submitted.  Answers should not be considered official coding advice, and we always encourage conversation and dialogue regarding our responses.  As best practice policy, always be sure to refer to your Official Coding Guidelines , Coding Clinic, CPT Assistant, etc.