Specify a Diagnosis

1 In the Diagnosis area, do one or more of the following:

Notes:   • 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. • If you specify a diagnosis that is considered inappropriate for the patient’s age or sex, a message might appear at the top of the page. 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, in-office phlebotomist (IOP) users will be unable to place the order until they 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. Click the appropriate tab and select the check box next to each appropriate diagnosis, or click Select All to add all of the listed diagnoses to the order.

Any diagnoses used for this patient within the past year appear on the Patient Specific tab. Patient-specific codes also appear 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 previously existed in the system. (The number of diagnoses imported is determined by an administrator.) Any codes retrieved from the external system are added to the Patient Specific tab, but no previously existing codes are removed.

The 15 most frequently used diagnoses appear on the Client Favorites tab (excluding any written diagnoses). You can optionally hide that tab via your user profile.

If an asterisk (*) appears next to a diagnosis name, you can add that diagnosis to the order, but if a physician or hospital staff member subsequently edits the order, that person will be prompted to provide a higher level of specificity.

Notes:   • If the tab contains more than the allowed number of diagnoses, a message appears when you click Select All, and none of the diagnoses are added. You can use this feature only if the tab contains no more than the allowed number of diagnoses. • For information about setting your default group or managing your favorite diagnose, see Manage Favorites via Order Entry.

• Specify one or more diagnoses:

a In the Diagnosis box, type a complete or partial diagnosis code or name. You must type at least two characters that are not asterisks (*).

To specify multiple codes or names at once, separate the entries with commas but omit any spaces (such as E232,R2241).

By default, the system will search for the specified text only until an exact match is found. (For example, if you type C85, the search stops as soon as code C85is found.) To see a list of all of the matching items even if an exact match is found, include an asterisk (*) in the code or name. 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.

If the lab supports the use of written diagnoses, you can type a written diagnosis, depending on your facility type.

b Click Search.

If you did not include an asterisk, and an exact match was found, the search stops, and the code is automatically selected and appears in the ICD Diagnosis Codes area. Go to step 2.

If you included an asterisk in the code or name, or if an exact match was not found, all of the matching codes appear in the Diagnosis area. If you did not include an asterisk, the specified search string is highlighted in yellow.

Up to 15 matching codes are displayed. If more than 15 matching codes were found, click More to see the additional codes.

c Select the check box next to each appropriate diagnosis.

Notes:   • If you selected a written diagnosis (that is, a diagnosis that is not preceded by a diagnosis code), in the ICD Diagnosis Codes area, the word Written precedes the diagnosis. You can add up to ten written diagnoses in addition to the allowed number of diagnosis codes. • If an asterisk (*) appears next to a diagnosis name, you can add that diagnosis to the order, but if a physician or hospital staff member subsequently edits the order, that person will be prompted to provide a higher level of specificity.

• Remove one or more diagnoses:

• To remove all of the codes, click Remove All in the ICD Diagnosis Codes area.

• To remove an individual code, clear the check box in the Diagnosis area, or click in front of the code in the ICD Diagnosis Codes area.

2 Specify a test (as described in Specify a Test).