Clarence Smiley MPH, MT (ASCP)Clarence Smiley MPH, MT (ASCP)

Documenting outside provider lab visits

Documenting outside provider lab visits

ObjectiveObjective

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

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

PrerequisitesPrerequisites

• 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 ServiceIndian 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 dialogExample 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

Example of provider name appearing in Visit tab

Create the actual visitCreate 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

The above items will prevent “orphan labs” in RPMS

Create the visitCreate the visit

Click on the “Visit Information” tab.

Click on Purpose of VisitClick on Purpose of Visit

Click on ICD Pick List tabClick on ICD Pick List tab

Select Laboratory ICD listSelect Laboratory ICD list

Click on Laboratory ProceduresClick on Laboratory Procedures

Select the Laboratory Procedures box.

“Lab Procedures” ICD code should now appear in Visit

Diagnosis box

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

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

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”

Diagnosis lookup box appears with description, click “OK”

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

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

POV now added to visitPOV now added to visit

Outside lab ordersOutside 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

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.

Click on Visit tab to select secondary provider.

Select outside provider from list of “All Providers”

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 completeVisit 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 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.