Resolved Documentation

[DematriusW_69730]

In general, in physican documentation, if they give the definition of a diagnosis, instead of plainly saying that diagnosis, could we could it still. For instance they list difficulty sleeping, is it ok to just code insomnia unspecified?

 

[Lori]

ICD-10-CM guideline 1.A.19

Code assignment and Clinical Criteria The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

Coding must be based on provider documentation. This guideline is not a new concept, although it had not been explicitly included in the official coding guidelines until now. Coding Clinic and the official coding guidelines have always stated that code assignment should be based on provider documentation. As has been repeatedly stated in Coding Clinic over the years, diagnosing a patient’s condition is solely the responsibility of the provider. Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis, can “diagnose” the patient. As also stated in Coding Clinic in the past, clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider’s clinical judgment, or eliminate the need for provider documentation regarding the clinical significance of a patient’s medical condition.

While physicians may use a particular clinical definition or set of clinical criteria to establish a diagnosis, the code is based on his/her documentation, not on a particular clinical definition or criteria. In other words, regardless of whether a physician uses the new clinical criteria for sepsis, the old criteria, his personal clinical judgment, or something else to decide a patient has sepsis (and document it as such), the code for sepsis is the same-as long as sepsis is documented, regardless of how the diagnosis was arrived at, the code for sepsis can be assigned. Coders should not be disregarding physician documentation and deciding on their own, based on clinical criteria, abnormal test results, etc., whether or not a condition should be coded. For example, if the physician documents sepsis and the coder assigns the code for sepsis, and a clinical validation reviewer later disagrees with the physician’s diagnosis, that is a clinical issue, but it is not a coding error. By the same token, coders shouldn’t be coding sepsis in the absence of physician documentation because they believe the patient meets sepsis clinical criteria. A facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system.

To summarize the above referenced information, the content in Guideline I.A.19 is not a new concept. The guideline reaffirms the long standing principle that coding should be ultimately based on provider’s documentation. Furthermore, coders should not exclude coding a reportable diagnosis that is documented by a provider based solely on the coder’s interpretation of clinical indicators or a perceived lack thereof. Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis, can “diagnose” the patient.

https://www.medpartners.com/guideline-19-code-assignment-clinical-criteria/