Corporate Compliance

Order with no diagnosis code

Compliance Monitor, November 4, 2005

Q: If an outpatient comes to the hospital for testing and the physician order does not contain a diagnosis, is it appropriate for the coding staff to contact the physician's office to obtain a diagnosis? Also, if the diagnosis code written on the order is incorrect (for example, missing a fifth digit) is it appropriate to contact the physician's office or can the coder use the correct code without contacting the physician's office? In other words, what are the current requirements for an outpatient diagnostic order and can you cite your sources?

A: According to Medicare's conditions of participations for hospitals (42 CFR Ch IV) and the Medicare audit manual, the following items are required for all outpatient orders:

  • Date

  • Patient name printed

  • Test or procedure to be performed

  • Any and all diagnosis

  • Printed physician name and signature (signature can be handwritten, rubber stamp, or electronic signature).

    These are the standard items required; however, states can add or delete items. The individual would need to contact the Medical State Association to inquire about requirements under their state's Medical Practice Act.

    If the diagnosis is missing or incorrect, the hospital staff should call the physician's office and seek clarification. The hospital staff should document the following items:

  • Name of provider called

  • Date

  • Time

  • Person they spoke with

  • Diagnosis or diagnosis code given

    This information needs to be written within the medical record in the event of an audit. Once the information is obtained, the hospital staff, at minimum, should initial the information received and date and time of his/her entry.

    It would not be appropriate for the hospital staff member to alter the order without physician approval in advance.

    This answer was provided by Tracy Livingston CCS, CCSP, quality assurance director of the The Coding Center in Birmingham, AL.

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