Coding, Classification and Reimbursement

pulling diagnosis from paragraph or from diagnosis put in EHR

  • 1.  pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 12-11-2014 16:57
    Our facility is questioning the coders and why they cannot "pull" diagnosis from a paragraph or from the EHR and put them down in a list for a discharge summary.  This is to help list all the diagnosis by pulling from a paragraph in the discharge summary or from the discharge instructions given by the provider.   They are wanting to cut down or eliminate queries and/or point out to the physicians what diagnosis to use.  I do not feel this is ethical or legal really.   I have been taught that the provider has to list the diagnosis. 
    Is there something from CMS or on the federal level or in guidelines that documents why we cannot.  

    Donna Winchell, RHIT
    HIM Director

  • 2.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 12-12-2014 09:56

    Donna you are 100% correct – that was be totally unethical and against all guidelines.


    Karen Mathias, RHIA

    Florida Hospital Waterman |Health Information Services, Director | 352-253-3328



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  • 3.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 12-12-2014 11:38

    As a compliance auditor I felt compelled to dig a little to provide you a few resources. I hope this helps :)

    A few points:

    1. HIPAA, CMS and the Federal Register refer to ICD 9 as the official coding guidelines. [see below]
    2. These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS.

    Therefore, any supporting documentation provided through AHIMA should suffice as "official".  All certified HIM professionals are required to adhere to their Standards of Ethical Coding.

    AHIMA Standards of ethical coding requires the coder to:

    • "Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation"
    • "Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities."

    This would apply if the diagnoses listed by the provider are incomplete and do not accurately reflect the conditions treated during the IP encounter.

    Providing/suggesting diagnosis codes to a provider to record on the discharge summary is leading and unethical (regardless if they are documented elsewhere in the record). It is the PROVIDER's responsibility to accurately and completely assign ALL diagnosis codes.  As such, a query may be submitted which requests the provider to verify if any diagnoses were overlooked or omitted from the discharge summary and offer dates and locations in the health record as a reference.

    Per AHIMA's practice brief:

    • "Ensure that the physician documents in the health record any clarification or additional information resulting from communication with coding staff."
    • Query should include: "Statement of the issue in the form of a question along with clinical indicators specified from the chart."
    • The query format should not sound presumptive, directing, prodding, probing, or as though the provider is being led to make an assumption.

    CMS: Inpatient coding documentation requirements:

    "When coding for an inpatient hospital stay, the diagnostic and procedural information and the beneficiary's discharge status (as the hospital coded and reported on its claim) must match both the attending physician description and the information contained in the beneficiary's medical record. Please review the "ICD-9-CM Official Guidelines for Coding and Reporting" and the "Medicare Claims Processing Manual", Chapter 6 to ensure complete and accurate coding."

    ICD 9 Guidelines: "Adherence to these ICD-9-CM guidelines when assigning diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Volumes 1-2) have been adopted under HIPAA for all healthcare settings."

    "In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis"

    Medicare Claims Processing Manual -Chapter 23 - Fee Schedule Administration and Coding Requirements

    10.2 - Inpatient Claim Diagnosis Reporting

    On inpatient claims providers must report the principal diagnosis. The principal diagnosis is the condition established after study to be chiefly responsible for the admission. Even though another diagnosis may be more severe than the principal diagnosis, the principal diagnosis, as defined above, is entered. Entering any other diagnosis may result in incorrect assignment of a Medicare Severity - Diagnosis Related Group (MS-DRG) and an incorrect payment to a hospital under PPS. See Chapter 25, Completing and Processing the Form CMS-1450 Data Set, for instructions about completing the claim.

    Other diagnoses codes are required on inpatient claims and are used in determining the appropriate MS-DRG. The provider reports the full codes for up to twenty four additional conditions if they coexisted at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay.


    Medicare Claims Processing Manual:

    Centers for Medicare and Medicaid Services and the National Center for Health Statistics. "ICD-9-CM Official Guidelines for Coding and Reporting." Available online at:

    AHIMA-Managing an Effective Query Process:


    Jeanne Matz

  • 4.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 12-18-2014 12:47
    Ok, stemming from this conversation is an issue that I'm dealing with.  We are not making a discharge summary that would be part of the medical record, but when it comes to entering diagnoses into the claim, must the claim reflect the exact codes that are on the EHR record? 
    My argument is, if we must put exactly what the physician put in hs A&P only then we are basically over educated data entry  staff.  Most of my physicians do not know the codes and cannot properly code according to rank order guidelines and/or coding specificity.  We would be bringing every chart back to them if we had to code from the codes they have listed. 

    Most physicians that I work with just tell the coders to change it on the claim according to the Coding Guidelines and they don't want to see it because they do not have the time to become certified coders. I am working on developing a policy to put this in place, as I have found documentation that this is appropriate. 

    Thanks for listening.  Thoughts are appreciated. 

    Jennifer J. Cline, RHIA, CPPM
    Director Coding & Access
    Aultman MSO (Physician Enterprise)

  • 5.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 12-19-2014 10:11

    "Must the claim reflect the exact codes that are on the EHR record? Most of my physicians do not know the codes and cannot properly code according to rank order guidelines and/or coding specificity. We would be bringing every chart back to them if we had to code from the codes they have listed."

    Your codes (on the claim) must reflect the exact DIAGNOSIS/ES that are supported by the clinical documentation of the provider.  The provider is not required to select a code but a diagnosis.

    CMS Documentation Guidelines state:


    1. The medical record should be complete and legible
    2. The documentation of each patient encounter should include:
      1. reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;
      2. assessment, clinical impression, or diagnosis;
      3. plan for care; and
      4. date and legible identity of the observer.
    3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
    4. Past and present diagnoses should be accessible to the treating and/or consulting physician.
    5. Appropriate health risk factors should be identified.
    6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.
    7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

    "basically over educated data entry staff".

    We are NOT clinicians and it is not our role to question the providers' clinical opinion.  We ARE however educated to understand pathology in order to know when there is a discrepancy in the record that needs to be clarified by the provider.  We cannot suggest or lead, but provide them the conflicting information and ask for them to clarify.  The objective is to teach providers the correct way to document their findings; educate them on documenting specificity, POA, making clinical associations when necessary, so that a query is not needed.

    I understand your frustration; however, it is the provider's responsibility (legally and ethically) to correctly document the care that they provide. It is our job to interpret the most appropriate code based on their documentation.

    Jeanne Matz

  • 6.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 12-19-2014 14:13
    Hello Jennifer,

    I understand your frustration and would like some clarification on this as well.  While I understand that providers are not required by coding guidelines to select a code our EHR requires that they attach a code to orders etc which are then documented in the EHR.  For example the "free text" will state something like Type II diabetes with neuropathy, but the provider will attach 250.00 to the A1c order.  We code the 250.60 and 357.2 according to their documentation, not the 250.00 code that they selected for the lab order.  I know I am coding appropriately, but as a coder it bothers me that it is not the same documentation throughout the chart note.  Having said that I know what the doctors really meant and I do not ask them to amend every EHR note where the diagnosis documented from a code they selected does not match exactly to their free text documentation.  I know this is not a perfect system and would really like to hear how others are handling this situation.

    Kimberlie Kennard
    CCS-P, Patient Billing Representative

  • 7.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 12-12-2014 11:55
    I agree it would not be appropriate for a coder to pull those diagnoses into a list to complete a discharge summary for the physician.  However, a coder may take diagnoses from any physician documentation within that current encounter.  See Coding Clinic 1st Qtr 2014, pages 11-13. 

    Documentation is not limited to the face sheet, discharge summary, progress notes, history and physical, or other report designed to capture diagnostic information. This advice refers only to inpatient coding.

    Angie Comfort, RHIA, CDIP, CCS
    Senior Director, HIM Practice Excellence

  • 8.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 12-21-2014 14:18
    Hello.  I have a couple of comments to make on this topic.

    First, I am in complete agreement with Ms. Comfort.  As long as documention gleaned from different sources within the medical record is not contradicted by the Attending Physician and that source is from a qualified provider as defined in "the guidelines", it may be used for coding purposes.  In rare situations where the Attending documentation contradicts the other source, I tend to code according to the Attending's opinion.  Very rarely would I query for clarification.

    Second, I totally disagree that coding must "match" that assigned by a physician in an EHR.  As stated by others, there is no requirement that physicians must assign codes associated with conditions or procedures.  Physicians are required to document, not code.  In this situation the problem is with the EHR, not the physician nor the coder.  I do not consider codes "assigned" by physicians as documentation, especially when the codes are obviously in error.  In addition to the excellent example of diabetic neuropathy, another common error one sees in these situations is the assignenment of 401.9 (Htn) in conjunction with a code for chronic renal failure (585.X).  I would no more expect a physician to know these coding requirements any more than a coder should be expected to make a diagnosis based on lab values.  As I have stated before, "Physicians are required to document, coders are required to code."

    One final note.  Think of the problems that would be created if codes assigned by physicians in an EHR are considered as "documentation".  As coders, we are required to assign codes based on our code of ethics.  If codes are errantly entered into the EHR are considered "valid", what is the recourse?  We are obligated to assign codes according to the various guidelines, starting with the UHDDS  and ICD-9-CM ( hope soon to be I-10) requirements down to special situation guidelines published in Coding Clinic.  The only option I can see under such circumstances would be to query the physician every time an incorrect code is assigned by the physician.  Would you really want to do that?  In my opinion, this would only serve to strengthen one of the arguements made by certain parties that ICD-10 should be delayed.  That arguement, which I totally disagree with, is that "physicans need to learn all the new codes". 

    One more time.  Physicians are responsible for proper documentation.  Coders are responsible for translating that documentation into accurate codes.

    Thank you,

    Lawrence Barr

  • 9.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 12-29-2014 07:52
    " See Coding Clinic 1st Qtr 2014, pages 11-13. "

    I wanted to review this CC and was not able to find this statement.  Is this the correct citation/local?

    Very intersting conversation and see this issue at the facility I work at.

    Veronica Anderson
    Medical Records Technician

  • 10.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 12-30-2014 11:10
    Hi Veronica,

    Angie is citing the correct Coding Clinic. It is found in the Ask the Editor section of 1st Qtr 2014, pages 11-13.

    Melanie Endicott
    Senior Director, Coding & CDI Products Development

  • 11.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 01-03-2015 11:25
    Hello.  I am a little behind in my e-mail.  If someone else has already addressed this, I apologize.  I found the information in Coding Clinic, 2nd Quarter 2000, pp. 17-18.  Bottom line, clear and consistent documentation may be coded from any source document within the medical record.  I guess an exclusion should be made for pathology reports not confirmed by an "attending" physician.  I believe the key phrase regarding Guideline ODX#2 is "what appears to be a current diagnosis".

    Lawrence Barr

  • 12.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 11 days ago
    Hi Lawrence,
    Will you be able to provide me with a link to access ODX#2 or how to get to ODX#2?

    Sherika Charles
    Billing & Coding Compliance Consultant

  • 13.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 01-06-2015 15:53

    The reference to CC1Q2014 pgs11-13 are correct.  I think that where the confusion is coming it that CC issued two 1Q2014 Coding Clinics - one for ICD-9 and one for ICD-10.  The information referenced is in 1Q (ICD-10) 2014 pgs 11-13.

    Hope this helps,

    Kathy Completa
    Coding and Documentation Educator

  • 14.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 01-13-2015 12:26
    Thanks for all of your resources and discussion!  I'm not looking to change a diagnosis without the physician's documentation, but we've been told by our contractor that we can't change even the rank order of diagnoses on the claim, or code according to Coding Guidelines.
    For example, the patient comes into the physician's office with Cough and ends up with a diagnosis of pneumonia.  The doctor lists both the cough and the pneumonia in his Assessment.  As a coder, we are to not add the cough and just code the pneumonia.  We are being told that we have to enter on the claim EXACTLY how and what the dr. entered on the EHR. 
    The problem that I'm noticing is the EHR.  The EHR is forcing the doctors to choose an ICD-9/ICD-10 code and it is usually not the correct code, per his documentation above in the visit's note.  Any suggestions on how I can correct this...without having to send every chart back to the physicians?  With 22 practices and over 104 physicians, this could be a nightmare!!
    Thanks again for your discussions. 

    Jennifer J. Cline, RHIA, CPPM
    Director Coding & Access
    Aultman MSO (Physician Enterprise)

  • 15.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 01-14-2015 19:40
    How frustrating Jennifer and I completely understand.  I addressed the issue of the providers having to pick ICD codes with our software vender representative today and was told that it was an issue of educating the providers and that would be my job to do...not sure quite where that leaves me yet, would prefer not to reinvent the wheel so I will be doing research as to how other clinics are handling this situation.

    Concerning your contractor not allowing you to code according to coding guidelines, I am highly suspect. Is there a written policy on this and verification that this policy is agreed upon by the payers?  From what I understand, if that is how the contracts with the insurances are written up then you should be covered, otherwise I do not understand why/where they would be coming up with this kind of a rule.  We bill several private insurances as well as Medicare/Medicaid and each of them have payment policies that vary some, mostly in the area of CPT and modifiers, but not to the extent that diagnosis coding guidelines are not allowed. 

    Kimberlie Kennard
    CCS-P, Patient Billing Representative

  • 16.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 01-15-2015 09:57
    What we are seeing is a problem with physicians being required or allowed to "pull" a code from a drop down box or list.  What are the chances they will select the correct code?  I have had this conversation with facilities multiple times over the last year - and it has to stop. Physicians are not trained coders and should be documenting their actual clinical diagnosis, not a canned choice from the EHR, and they should not be assigned ICD-9 or ICD-10 codes.   In many cases, the record is locked and the only one who can go back and change the code is the provider, and we know that is not always going to happen.   Instead of producing more accurate data, we see a trend towards even more inaccurate data as facilities follow this practice. 

    Saying that - all of the Final Diagnoses do not have to be listed in the Discharge  Summary to assign a code at the time of discharge.  If the diagnoses are established in other parts of the record by a qualified provider (MD, DO, PA, FNP) and there is no attending physician contradicting statement/information, codes may be assigned for that condition.  Example,  the patient has stage III CKD which is being followed by another physician, and the attending does not include it in the Discharge Summary, it can still be assigned a code and reported.

    Susan Roehl
    Eide Bailly, LLP

  • 17.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 01-15-2015 10:00
    Since that's true, what we need is for vendors to stop providing drop-down lists. They're obviously leading to non-compliant documentation.

    Sent from my iPod

  • 18.  RE: pulling diagnosis from paragraph or from diagnosis put in EHR

    Posted 01-15-2015 10:33
    Could someone address this in an outpatient physical therapy center. I am the transcriptionist.  I am still very new to coding.  I do have my CPC-A and am currently in the process of reviewing/studying for my CCS.  According to my knowledge base, I am a seeing a scenario in my provider's office that confuses me.  When I have asked about it, I get told it is just because I am new to coding and do not understand and physical therapy is handled different from 'regular coding'.  Hypothetical situation - patient is referred for knee pain due to 'arthritis'.  I have been told to just put knee pain in the diagnosis in the header of the report.  However, on assessment, the provider might say 'apparent' and he/she always uses this term in every diagnosis 'apparent' and then he will go on to say...stiffness, dysfunction,  or arthritis..however in the subjective history, the patient is referred for knee pain.  Patient has a history of arthritis.  Pain is a symptom of arthritis.  The guidelines states that if you know the condition causing the pain, you put the condition.  This will go for shoulder pain, neck pain, whatever...they want pain put in as diagnosis even though in the assessment he/she does not state 'knee pain due to arthritis' or neck pain due to ? etc, etc.   even if the condition might be an impaired mobility after shoulder replacement.  My question is I know they treat this in physical therapy addressing pain and not necessarily the arthritis as an example, but is it correct to just put knee pain, when the pain is a symptom of arthritis.  Thank you for your help and if someone can give some good reference resources on physical therapy, I would be very grateful. 

    Debra Egleston