I am looking for guidance on LOINC code to be used for physician note on an outpatient visit. Can someone help me how to identify the right code, as i see there are many codes defined for physician notes on an outpatient.
Few example codes i referred:
75476-2
34758-3
78326-6
Any help on this topic is greatly appreciated. Thanks in Advance !
Hi Suresh,
I don’t think there is a single correct answer for this question.
In an ambulatory setting, the patient may be treated by a CRNP, RN, MD, etc. so you may want to map to different LOINC codes based on additional context such as the outpatient department and/or the logged-in clinician’s National Provider Identifier (NPI) information that would categorize them as a physician, nurse, CRNP, or another specialist.
Additionally, the nurse may document a rooming and/or initial evaluation note that is separate from the final physician summary note.
If your implementation only allows mapping to a single code, then it may require the use of a generic LOINC code like 34108-1 Outpatient Note. You would then need the additional context provided by Clinician’s NPI and department to confirm it was indeed a note made by specific category of clinician (e.g. nurse, MD, etc.) operating in an outpatient role in an outpatient department at the time the note was submitted into the EHR.
Department can be an important part of the context as hospital based emergency rooms are often categorized as an outpatient department for billing purposes even though it is within the physical structure of the hospital. The same may be true of other departments such as radiology (i.e. imaging) where the hospital based department provides services for both inpatient and outpatient scenarios.
Keep in mind that the entire context most likely should not be carried by the LOINC code and that other code systems maybe in play that should be leveraged to define the full context of the note.
I hope this helps.
John