Coding Clinic, Fourth Quarter 2015: Page 34
Coding advice or code assignments contained in this issue effective with discharges November 13, 2015.
Since our facility has converted to an electronic health record, providers have the capability to list the ICD-10-CM diagnosis code instead of a descriptive diagnostic statement. We are seeking clarification for whether there is an official policy or guideline requiring providers to record a written diagnosis in lieu of an ICD-10-CM code number?
Yes, there are regulatory and accreditation directives that require providers to supply documentation in order to support code assignment. Providers need to have the ability to specifically document the patient's diagnosis, condition and/or problem. It is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement. ICD-10-CM is a statistical classification, per se, it is not a diagnosis. Some ICD-10-CM codes include multiple different clinical diagnoses and it can be of clinical importance to convey these diagnoses specifically in the record. Also some diagnoses require more than one ICD-10-CM code to fully convey the patient's condition. It is the provider's responsibility to provide clear and legible documentation of a diagnosis, which is then translated to a code for external reporting purposes.
While we're aware that some payers may allow submission of code numbers on lab orders, Coding Clinic recommends that physicians provide narrative diagnoses/signs/symptoms as the reason for ordering the test.