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

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

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. 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.

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

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

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

Example of New Visit dialog

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.

Example of provider name appearing in Visit tab

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

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

Click on Purpose of Visit

Click on ICD Pick List tab

Select Laboratory ICD list

Click on Laboratory Procedures Select the Laboratory Procedures box.

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

Select a POV Click on Historical POV tab

Outside lab orders should have an ICD-9 code that you enter or select from list.

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

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

Diagnosis lookup box appears with description, click “OK”

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

POV now added to visit

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. 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.

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

Click on Visit tab to select secondary provider.

Select outside provider from list of “All Providers”

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

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

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). 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).

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. Can use ICD-9 Laboratory pick list. Can use POV provided by the physician ordering the lab, usually an ICD-9 code.