Coding, Classification and Reimbursement

Doctors incorporating ICD-10 codes in prog notes

  • 1.  Doctors incorporating ICD-10 codes in prog notes

    Posted 12-31-2018 13:07
    I have multiple doctors who incorporate ICD-10-CM codes into the Plan section of their progress notes. However, often the text and the chosen code are contrary to official coding guidelines (R41.89 for cognitive impairment instead of G31.84) or the text is specific but the chosen code is not (J96.90 for chronic resp failure with hypoxia). I generally code based on the actual text, but always feel uncomfortable that the providers are putting codes into their notes that don't match what is actually coded. I think this practice has to do with them billing separately from the facility and the ICD-10 codes in the notes are what they are using to bill. Does anyone have advice on this situation? Is it an issue that needs to be addressed, or can I just continue to code based on the actual text and let them document whatever codes they want even if they're inaccurate? Could this cause billing or quality issues due to the discrepancy? If it does need to be addressed, what is the best way to go about it?

    Jacqueline Mccauley
    HIM Director

  • 2.  RE: Doctors incorporating ICD-10 codes in prog notes

    Posted 01-02-2019 08:50
    Jacqueline - I also have this happening in our clinic. Ours has to do with the ambulatory system we are currently using. There are so many choices that our providers will choose what they think is close and then change the wording. The problem is that the  code will follow the patient's chart incorrectly.

    As we have time we do address it with the provider's nurse to get the correct code on the patient's record. Otherwise we simply code from the documentation and the detailed assessment. I think it is a problem with EMRs!

    Beth Kosman, RHIT, CCS, CCS-P
    HIM Director
    Ringgold County Hospital

  • 3.  RE: Doctors incorporating ICD-10 codes in prog notes

    Posted 01-02-2019 10:15
    ​I never use the providers codes.  Your point that they don't know and follow coding guidelines is part of my issue.  The other is that I have to support/defend my code choices with provider documentation and I have always interpreted that as being their words.

    In my opinion it is easier to ignore their codes then worry about whether or not they have followed coding guidelines and/or coding clinic clarifications.

    Our providers can choose a code when they enter a diagnosis in the EHR problem list, but the code does not appear in a document if the problem list is pulled into the document.

    Kathy Completa
    Coding and Documentation Educator

  • 4.  RE: Doctors incorporating ICD-10 codes in prog notes

    Posted 01-02-2019 11:59
    Coding Clinic addressed codes used in provider documentation a few years ago.  You might find this helpful:

    Code Number in Lieu of a Diagnosis

    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.

    Kristi Pollard, RHIT, CCS, CPC, CIRCC
    Senior Coding Consultant and AHIMA-Approved ICD-10-CM/PCS Trainer
    Haugen Consulting Group

  • 5.  RE: Doctors incorporating ICD-10 codes in prog notes

    Posted 01-02-2019 22:31
    Our physicians used to do this and we have lost in audits. We removed the ability for physicians to assign a specific code/ from our documents.

    Deanna Heinrich
    Director of HIM/Privacy Officer