Awareness : OBC Tips

Diagnosis Codes on Requisitions

The following recommendations apply to all order entry mechanisms whether they are hard-copy requisitions or electronic/web-based systems. If the lab communicates diagnosis information either by listing diagnosis codes on paper requisitions or displaying them in pop-up boxes or other electronic displays, you must consider the compliance issues explained below.

The recommendations that follow serve to ensure the laboratory is not practicing inappropriate “code-steering.” Code steering occurs when a laboratory inappropriately influences an ordering physician to choose a diagnosis code that does not accurately report the patient’s condition or reason for ordering the test. Such practices are inappropriate because only the ordering physician should determine which diagnosis codes are appropriate. Usually, laboratories list the most commonly submitted diagnosis codes for convenience or reference in their order entry mechanisms.

Compliance Safeguards

If the laboratory lists, displays, and/or provides commonly used diagnosis information, the order entry system should incorporate the following compliance safeguards:

  • Multiple Choices: List as many codes as possible to avoid the appearance the lab is steering providers to use particular codes.
  • Include Blanks: Include multiple blanks or blank spaces or “Other” so that providers may enter particular diagnosis codes that may not be included in the list provided by the laboratory.

Disclaimer/Statement:

A statement should precede the listed diagnosis codes that indicates the list is provided only for convenience and that the provider should communicate the diagnosis code that most accurately reports the patient’s condition/diagnosis/reason for ordering the test. The statement should also clearly state that the physician should report the most accurate diagnosis code regardless of whether that code is listed on the requisition or not. An example of such a disclaimer/statement follows:

“The following diagnosis codes are listed as a convenience only. Ordering physicians should use the ICD-10 code that best describes the reason for performing the test, whether or not that code is listed below.”

Only List Accurate and Up-to-Date ICD-10 Codes: Make sure that the requisition only includes the most up-to-date and accurate diagnosis codes. To accomplish this, laboratories must pay attention to ICD-10 annual updates and periodically review their requisitions and electronic order entry systems. The latest ICD-10 update became effective October 1, 2016, and includes over 1,900 new codes and 300 deleted codes.

Highest Specificity: Ensure that all listed codes and descriptors are accurate, up-to-date, and include all requisite digits to allow for the greatest specificity possible. Remember that ICD-10 codes may include up to 7 digits.

OIG Highlights Prohibited Practices

The OIG’s Compliance Guidance for Clinical Laboratories (August, 1998) contains several examples of practices that laboratories should not follow concerning diagnosis information and codes. Specifically, the OIG warns laboratories NOT to:

  • use information provided by a physician from earlier dates of service.
  • create diagnosis information that has triggered reimbursement in the past.
  • use computer programs that automatically insert diagnosis codes without first receiving diagnosis information from the ordering physician.
  • “make up information for claim submission purposes.”

Compliance Policies and Procedures

When designing a requisition or electronic order entry system, clinical laboratories must take care to not engage in code-steering or any of the numerous other practices proscribed by applicable OIG compliance guidance. Providers should also implement compliance policies and procedures that dictate exactly what actions the laboratory takes in the event it receives missing, incomplete, or ambiguous diagnosis information from an ordering provider. These policies and procedures will ensure that the laboratory does not submit false claims, receive overpayments, or fail to comply with relevant OIG guidance. To accomplish all of the above, all clinical laboratories should create, adopt, and implement the following compliance policies and procedures:

  • If the laboratory receives an order without complete and clear diagnosis information, the laboratory should contact the ordering provider to obtain such information;
  • The laboratory should maintain documentation of all such contacts and the subsequent information provided by the ordering provider;
  • The laboratory should only accept/use diagnosis information to submit a claim that is received as part of the test order, and contemporaneous with the reason the provider ordered the test(s) for the patient; and
    • If the laboratory chooses to list commonly used diagnosis codes in its order entry systems, the laboratory should incorporate the requisition components recommended above.