Forum - Questions & Answers

May 20th, 2015 - lkwilliams

does anyone use Pathology orders as documentaton that a procedure was performed

May 20th, 2015 - petunia 195 

re: does anyone use Pathology orders as documentaton that a procedure was performed

I would not. An order is not proof that the test/procedure was done.

May 20th, 2015 -

re: does anyone use Pathology orders as documentaton that a procedure was performed

thats what i was taught as a coder, but the practice I work for stated that even thoght I did not have a complete documentation of a procedure being performed, it was stated that if i had a path order request that I could still bill for the procedure as that was proof the procedure was done. During my training as a coder i was told that not documented not done. I was just trying to find some guidance on this. The billing manager was upset that I would not allow the claim to be billed w/out the correct documentation as I could request the notes from the provider, but still bill for the procedure. I was trying to find some verification that this was not allowed without a procedure note stating it was done. Thanks for your answer:)

May 20th, 2015 - ginasn 12 

re: does anyone use Pathology orders as documentaton that a procedure was performed

Think about this logically, without the actual documentation from the provider, how can you properly bill for this? You can't because you don't know for sure what happened in that procedure room. Simply having orders for a pathology will not tell you if there was a problem that might have occured, causing the need to add a modifier, or if maybe there happen to be other billable charges that occured. Even with a pathology report, stating what was sent for pathology is not enough either. I don't think you will find "documentation" to support what is common knowledge with certified coders. You simply must have your providers documentation of what he/she did. That is the only way to bill for charges.



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