A couple of weeks ago, we published information on a Q 1 2012 Coding Clinic ruling on physicians using a diagnosis code in lieu of a written diagnosis. This has led to some questions, so we wanted to provide additional information.
Coding Clinic was asked about physicians choosing a diagnosis code in an EMR vs. using a written diagnosis--but this advice applies to handwritten or dictated notes as well. One important point that Coding Clinic made relates to something we see frequently--physicians just picking the diagnosis code and short descriptor of the code and using it as an assessment. Coding Clinic said:
"...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-9-CM is a statistical classification, per se, it is not a diagnosis. " (emphasis added).
Here's an example that we see frequently as an assessment:
250.40--Diabetes with renal manifestations
As you can see, this is not a diagnosis, but a category of diseases, or in ICD-9 terms, a statistical classification.
The clinician is responsible for providing a diagnosis, so they may need to add to the short descriptor of a diagnosis code in the EMR. For example:
250.40--Diabetes with renal manifestations - CKD 4 due to DM
This provides an actual assessment (diagnosis) of the patient's condition, that allows correct coding.
EMRs can be tremendous time savers, but physicians and clinicians must ensure that they meet coding and documentation requirements.
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