Specify a Diagnosis

1 In the Diagnoses section, do one or more of the following:

Notes:

• If you are a hospital staff member, the Diagnoses section does not appear unless the client requires a diagnosis or if Bill Type is set to Patient or Insurance.

• A diagnosis may or may not be required, depending on the client or insurance carrier.

• The ordering provider is responsible for determining the appropriate diagnosis codes for each patient. Diagnosis codes must be applicable to the patient’s symptoms or conditions and must be consistent with documentation in the patient’s medical record.

• In your user profile, you can specify whether or not the Diagnoses section should be collapsed when a diagnosis is not required. If the Diagnoses section is collapsed and you want to specify a diagnosis, click View Diagnoses. To collapse it at any time, click Hide Diagnoses.

• If you specify a diagnosis that is considered inappropriate for the patient’s age or sex, a message might appear in the Diagnoses section. You can still file the order, but it is recommended that you confirm the diagnosis and the patient’s age and sex.

• If you select a diagnosis code that the insurance carrier considers to be either a non‑diagnostic code, or a code that is inappropriate as a primary diagnosis, a message appears alerting you to select at least one primary diagnosis code. For non-diagnostic codes, you will be unable to place the order until you do so.

• If you select a diagnosis code that is specified as never being covered by the patient’s primary insurance carrier (unless an exception order code or diagnostic ICD code is also included on the order), a message appears reminding you to ensure that all relevant diagnosis codes are included with the order.

• Select one or more favorite diagnoses:

a In the select from list, click the appropriate group of favorites.

Note: The group that appears automatically is determined by the client being used for the order, the default group of favorite diagnoses (if any) associated with that client, and whether or not any patient-specific diagnoses exist. If no client appears in the Order Information section, the default client of your current lab or the carrier’s preferred lab (if applicable) is used. You can set your default client via your user profile. For information about setting your default group or managing your favorite diagnoses, see Manage Favorites via Streamlined Order Entry.

Any diagnoses used for the patient within the past year appear in the Patient Specific group. Other diagnoses can also appear in that group if you retrieved the patient information from an external system using a bridge that supports that feature, as long as diagnosis codes were included in the external system and the patient already existed in the system. The number of diagnoses imported is determined by an administrator. When patient-specific diagnoses are imported via a bridge, no previously existing codes are removed.

Your 15 most recently used diagnoses for your current lab appear in the Recently Ordered group. (If you subsequently add a test associated with a different lab, the items in that group might change.) You can optionally hide the Recently Ordered group via your user profile.

The favorites in the selected group appear on the page, including the diagnosis code and description.

If the group includes any diagnoses that require a higher level of specificity, all of the related codes appear in the list. For example, if the diagnosis code 487 was added to a group, that code would not appear. Instead, the more specific codes 4870, 4871, and 4878 would appear, and the code that requires a higher degree of specificity (such as 487*) would appear in parentheses after the diagnosis description.

b In the displayed list of favorites, click the appropriate item, or click Select All to add all of the displayed favorites to the order.

Each specified diagnosis appears in the Added Diagnoses area.

Note: If the group contains more than the allowed number of diagnoses, a message appears when you click Select All, and none of the codes are added. You can use this feature only if the group contains no more than the number of codes allowed.

• Specify one or more diagnoses. In the box in the upper-left corner of the section, type the complete diagnosis code and then press Enter. The diagnosis associated with that code appears in the Added Diagnoses area.

If you do not know the exact diagnosis code, type the first few characters of the code or description. A list of the first ten matching diagnoses appears. As you continue typing, this list displays more similar matches. When you see the appropriate diagnosis in the list, click that item to add it to the Added Diagnoses area.

Alternatively, follow these steps to search for a diagnosis:

a In the box, type at least two characters that are not an asterisk.

You can optionally include an asterisk as a wildcard. For example, to find all diagnosis codes that begin with C85 (such as C851, C8510, C8511, etc), you could type C85*. To find all diagnosis codes that end with 85 (such as A185, A1885, A3685, etc), you could type *85.

Note: If the search encompasses a code that requires higher specificity, the related codes appear, even if they do not exactly meet the search criteria. For example, if you search for *C85, the search results would include C850, C851, and so forth, even though those codes do not end in C85. This is because the code C85, which does meet the search criteria, requires higher specificity.

b Click Search.

c In the search results, click the appropriate item.

The specified diagnosis appears in the Added Diagnoses area.

• Remove one or more diagnoses. Click next to the code in the Added Diagnoses area. You can also remove all of the codes in this area by clicking Remove All.

Tips:

• If the description of a listed diagnosis is too long to display in its entirety, an ellipsis (...) appears. You can position the pointer over the diagnosis to see the complete description in a pop-up window.

• To sort the listed diagnoses, click the appropriate column heading. You can click the column heading again to reverse the sort order.

The codes are sorted based on the value of the digits from left to right, regardless of the length of the code. For example, when the codes are sorted in ascending order, code 1234 would come before code 234. In addition, any codes that begin with a letter are grouped together after the numeric codes.

2 If you are creating a standing order, provide the standing order details (as described in Specify Standing Order Details). Otherwise, specify at least one test (as described in Specify a Test).