L81.1 - Chloasma

Clinical Definition

A complete blood count (CBC) is a panel of blood tests that measures various components and characteristics of blood, including white blood cells (WBC), red blood cells (RBC), hemoglobin, hematocrit, and platelets. This test provides crucial information about a patient's overall health status and can help diagnose various conditions.

Documentation Requirements

• Test Components: Document each specific component being measured:

  • White blood cell count (WBC)

  • Red blood cell count (RBC)

  • Hemoglobin (Hgb)

  • Hematocrit (Hct)

  • Platelet count

  • Mean corpuscular volume (MCV)

• Clinical Indication: Document medical necessity through:

  • Specific signs/symptoms

  • Relevant diagnoses

  • Monitoring requirements for medications

• Timing/Frequency:

  • Document if routine or stat

  • Justify frequency if ordered multiple times

  • Note any standing orders

Common Synonyms

• Blood count

• Blood panel

• Complete blood work

• Blood test

• Full blood count (FBC)

• Hemogram

Coding Conflicts

Excludes1:

• Specific coagulation studies

• Hemoglobin electrophoresis

• Blood type testing

Scribing.io Automation

The AI scribe automatically identifies and captures:

• Key phrases indicating CBC orders ("check CBC," "get blood count")

• Clinical indications mentioned during patient encounter

• Frequency specifications

• Associated symptoms or conditions requiring monitoring

The system tags these elements appropriately for billing justification and creates structured documentation that supports medical necessity.