Coding, Classification & Reimbursement

1.  OP Order Criteria

Posted 06-19-2017 11:49
All -

Before the transition to ICD-10 we changed our facility policies to no longer accept just a diagnosis code on an outside order. We now require that providers write out the code description on all orders for OP diagnostic testing. For example, we would not accept "I10" but would accept "hypertension" on an order. We made this change because it is very easy to misinterpret the letter "O" for the number zero, the letter "I" for number one and so on.

I have been challenged by our finance team to take another look at this policy and consider allowing diagnosis codes again. I'm concerned about reverting back because we still receive quiet a few hand written orders.

My question is.... What are you doing in your facility? Do you allow just a diagnosis code on an order?

Jessica Dashkiewicz, MHA-HI, RHIA, CCS
AHIMA Approved ICD-10-CM/PCS Trainer
Director, HIM
Owensboro Health
(270) 417-6811 (Office)

2.  RE: OP Order Criteria

Posted 06-19-2017 12:30
Per coding  guidelines ... coder have to code by worded diagnosis or procedures that the physician documented also known as clinical documentation. Coders are not supposed to code by coders' inspired diagnosis codes such as" I10" in the chart. Patients has access to medical information and putting diagnosis or procedure codes in the chart in place of clinical documentation would be against coding guidelines and may cause a healthcare provider legal ramifications for noncompliance.

Charisse Smith
Senior HIM Consultant (Auditor)

3.  RE: OP Order Criteria

Posted 06-19-2017 12:57
Absolutely not.  It must be a written duagnosis.

Sent from my Verizon, Samsung Galaxy smartphone

4.  RE: OP Order Criteria

Posted 06-20-2017 10:26

When we first had to start checking for medical necessity, I  recall that ordering providers were supposed to supply the diagnosis code with the order.  This requirement caused an uproar with the providers because they weren't "coders".  We accept orders with diagnosis codes. 


Sheila Gage, RHIT, COC

Director Health Information Management

Lake Health District

700 South J Street

Lakeview, OR   97630

Phone # 541-947-7291