Code Numbers Instead of a Narrative Diagnosis

All too often, we see a diagnosis code written in the medical record, in lieu of a narrative diagnosis.  In those instances, we cannot code what has been written for two important reasons:

• Coding is done based on the narrative documentation in the medical record--with no narrative, no coding can take place
• There's no way of telling if the diagnosis code in the chart is correct (i.e., what the provider meant to code)

We get this question at least once a year--and sometimes it leads to lively exchanges.  Thankfully, Coding Clinic, Q1 2012, has decided to address it.  Their answer, in part reads:

"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. Therefore, 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 diagnosis."

So--the next time you're asked if a provider can just write the code in the chart--you'll know where to point them for clear guidance.