A Very Frequently Asked Question

We frequently are asked about "where CMS says" one thing or another.  First, you have to remember that CMS can't and won't address every possible situation.  By applying common rules and logic, you can usually know what CMS would do in a given situation.  One question we get a lot is:

Our doctors want to know why they can’t just write “250.40 –diabetes with renal manifestations” in the record and code 250.40—and where CMS says they can’t do this.

Our answer to this question is as follows:

CMS doesn’t write the rules for ICD-9 by themselves—and it would be impossible to write a rule for each and every possible situation that can occur.  The Official Coding Guidelines make it clear that a diagnosis must be supported by the medical record, and must affect the care of the patient.

The rules for ICD-9 are written by the four cooperating parties – the American Health Information Management Association, the National Center for Health Statistics, the American Hospital Association, as well as CMS.  All official interpretations not found in the coding guidelines are the responsibility of the American Hospital Association, via Coding Clinic.

A short diagnosis code description (like diabetes with renal manifestations) is just that—a description.  The word “manifestations” is not a diagnosis, it’s a category of conditions, and the physician is required to describe what disease in that category exists.  A physician can no more support an ICD-9 code by writing the description than they can support an E/M code by writing its description. 

Writing “Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family” does not support a 99214, it’s a description of a 99214. Similarly, in order to support a diagnosis, the physician must document what’s wrong with the patient.

So, with diagnosis coding, the physician must document in the medical record what is actually wrong with the patient--not a category of what's wrong with the patient.