Coding from a lab?????? Help please :)

[Audrey Widner]

Physician or NP notes on documentation (that is in the medical record) that at the hospital the patient had an ANC of 800, and therefore qualified for Neupogen, so they were sent back to the office to receive this.
My question is...... is it acceptable to code from the ANC of 800? (which if your ANC drops below 1,000 it is called neutropenia dx of 288.00)

Is there some rule that you can not code from a lab result? Are labs not included in what makes up medical record components? Which we code from the medical record?

 

[Alicia Scott]

You can not code from lab report because you are not qualified as a coder to read labs and give a dx. The physician or NP has to state it in the documentation. It doesn't matter if you know or not. Sorry.

 

[Audrey Widner]

Thank you Alicia, I was thinking that I needed to get the NP to state that in her note rather than just stating the ANC was 800 as she did. Just wanted to clarify.