Health Information Technologies and Processes

outside lab--attach another provider results to our order. Medical Records Question.

  • 1.  outside lab--attach another provider results to our order. Medical Records Question.

    Posted 09-09-2019 13:25

    All -

    I have a situation I need help with as I'm getting questions from Medical Records.

    Sometimes our provider orders a limited lab test, like hemoglobin, which gets sent to an outside lab.  The same lab performs the whole CBC for another provider, and sends the results with a CC to our physician rather than performing the whole test again.  So our provider signs the hardcopy that was CC to him, and then it goes to medical records.  Our medical records team refuses to attach that signed CC copy to our doctors order since it's a CBC from an outside provider.  Our COO is telling medical records they must do this.  I want to know what best practice is?

    Technically, our provider ordered the hemoglobin, and is reviewing the resulting hemoglobin.  



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    Sarah Jackson
    Compliance Manager
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  • 2.  RE: outside lab--attach another provider results to our order. Medical Records Question.

    Posted 09-19-2019 16:15
    Edited by Christina Ordonia 09-19-2019 16:16
    I really hope this lab is NOT submitting a claim for a test that they did not perform.  If they are, then that is a problem.

    If the physician only ordered a hemoglobin, then that is what the lab should provide.  They should not be pulling a copy of a lab test taken on potentially a different day.

    The claim submitted needs to tie back to the actual order.

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    Chris Ordonia, MPH, RHIA, CPHQ
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  • 3.  RE: outside lab--attach another provider results to our order. Medical Records Question.

    Posted 09-20-2019 10:45

    Hi Christina, 

    I don't believe they are.  In fact, I think what they are doing is taking reasonable measures to control the cost of healthcare - both for the patient and for the plan.  The HGB is part of the CBC, so they are opting to send the result from Provider A to Provider B rather than repeat a portion of the test again on the same day.  Does that make sense?  



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    Sarah Jackson
    Compliance Manager
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