Compliance Focus
Coding/Documentation Guidelines for PT and PTT Studies
Certain laboratory tests are under consistent scrutiny due to high frequency and require the ordering practitioner to provide specific medical rationale for the test.
The following guidance should be used when ordering Prothrombin Times (PT) and Partial Thromboplastin Times (PTT):
If a PT is ordered to assess a patient's response to therapeutic anticoagulation (i.e. coumadin therapy), the ordering provider must indicate the reason narratively “Patient is on Coumadin” or write the diagnosis code V58.61 on the laboratory requisition (preferred method).
If PT or PTT are being ordered for the following list of symptoms and conditions, they must be clearly documented on the laboratory requisition:
• Symptoms of bleeding such as hematuria, epistaxis, hemoptysis, ecchymosis or actual unspecified hemorrhage without a definitive diagnosis; and/or
• Atrial fibrillation, DVT, PE, fractures, blood vessel trauma, limb pain, circulatory system disorders and transplant history. In urgent care, indicate if the PTT is to further evaluate known conditions with an associated risk of hemorrhage or thrombosis, as well as signs and symptoms of unspecified hemorrhage.
In the absence of a definitive diagnosis, document the relevant symptoms on the laboratory requisition. Plus, avoid the use of “rule out…” as it cannot be translated into coding format and will not support the medical necessity.
When ordering PT and PTT together, be sure the lab requisition lists all relevant diagnoses, symptoms and pertinent history.
If you have any questions please contact Neil Walsh at 617-732-9377 (cwalsh6@partners.org) or Cindy Vieira at 617-732-6646 (cvieira@partners.org)