Code Numbers in Lieu of a Diagnosis-- Dangers in the EMR

One of the most frequent questions I get asked is "isn't selecting the diagnosis (code) in the EMR good enough documentation?" The answer is no, and a recent Coding Clinic broaches this subject.  I will expand a little on their thoughts.

Basically, Coding Clinic Q4 2015 received a question if physicians could use a code number in lieu of a diagnosis. Their answer was a resounding no--but they went a little further.

Coding Clinic told the inquirer that it was not appropriate for providers select a code number from a list of codes in place of a written diagnostic statement.

Their rationale is that the ICD-10 is a statistical classification, not a diagnosis. Further, they indicated that many clinical diagnoses may be included in an ICD-10 code, and it may be important to document these diagnoses.  They went on to say that it was the provider's responsibility to provide clear documentation of a diagnosis.

The abbreviated ICD-10 descriptions are often so shortened they make no sense--and can't be called a diagnosis.  One reason that writing a code in lieu of a diagnosis is inappropriate is that the code chosen may simply be wrong--without a narrative description (of sufficient specificity), there's no way to even know if it's right.  Coding is done from a narrative, not from a number.

This issue was very common in ICD-9.  Think back to all of the "Diabetes with _____________manifestations".  These codes were chosen all the time, and could not be supported--there was no way to know what the "manifestation" was, without further description by the physician.  A manifestation isn't a disease description--it's a whole array of possible diseases. Without further documentation by the physician, it's not possible to know what that disease is.  In ICD-10, with its added complexity, this issue will arise over and over again.  It is the clinician's responsibility to ensure that their documentation makes sense, and includes sufficient information to validate that the code chosen is correct.  The act of choosing a code is not enough.

EMRs are great time savers.  But they are not a substitute for adequate documentation by the physician to determine if the selected code is correct.

So, I recently read a funny blog....

About Coding of all things.  It's called Coder Coach.  And the author does a code for the day, with a focus on humor.  I'm not as funny as she is, so I'm not even going to try.  But I think that I will try to be more diligent about posting--and I think I'll try to do a code a day (or week...or something).

Let's face it--ICD-10 has been a royal pain of an implementation.  So, by focusing on a new code with some regularity, I might be able to lend a hand.  No time like the present!

We'll start off, not with a code, but with at category.  This category may be the most misused category of codes I've ever seen.

I've been coding for more years than I like to admit.  Let's say north of 30.  While I've seen instances where these codes (and their predecessors in ICD-9) could have been used correctly, I've never actually seen them used correctly.  They are: Neoplasms of  Uncertain Behavior.  In ICD-10 they are found in the section Neoplasms of Uncertain Behavior, Polycythemia Vera and Myelodysplastic Disorders (D37-D48).

When I see a code for neoplasm of uncertain behavior submitted, no matter the body area, it's always because:

1. The physician hasn't biopsied the lesion yet, and so he/she is uncertain of the histology; or
2. The physician has biopsied the lesion, but hasn't yet received the pathology report

Neither of these is the correct usage of the code.  The beginning of the code section explains the correct use of the codes, but unfortunately, one of the downsides of Electronic Health Records (EHRs) is that none of these instructions are visible to most users.  Here's the instruction, straight from the ICD-10:

Note: Categories D37-D44, and D48 classify by site neoplasms of uncertain behavior, i.e., histologic confirmation whether the neoplasm is malignant or benign cannot be made.

As you might guess, the instances where you can correctly use these codes are relatively rare.  So, unless the pathologist cannot tell you whether to neoplasm is benign or malignant, these codes should not be used. 

This code category points out the importance of the coding instructions and guidelines.  As noted, these are generally lost in an EHR--that's not to say EHRs are bad, simply that they have their limitations.   So, what's a coder (or the physician who is coding) to do?  I strongly recommend that coders AND physicians read the sections of the Coding Guidelines that apply to them.  That means any specialty specific guidelines, and the entire Outpatient coding section.  You should also review the section of the code book that includes common codes you use.  And, when faced with the new and unusual (like these), take a quick glance at the book to see if there are special instructions like we found here. 

Now, if you have an EHR, you don't have to buy the code book to do that.  Every year, we post a full text copy of the ICD-10 on HCC University.

I'm going to do my best to keep posting these coding tips.  If I fall behind, feel free to email me at Coding@scanhealthplan.com to remind me.  I sometimes suffer from mild memory loss, NOS (R41.3)

New Content on HCCUniversity.com

There’s been a lot of activity on HCC University!  Since my last email, we’ve posted several new things:

First, an updated Pocket Documentation Tip Sheet, which includes instructions for ICD-10 guidelines.  This tip sheet can be printed and folded to fit in a lab coat pocket, and will help clinicians meet some of the documentation challenges they face on a daily basis.

Next, we’ve updated the Primary Care Superbill.  As before, it includes CPT  II codes that help you meet both 5 Star AND Fee-for-service PQRS requirements!  Now, it’s been updated to include ICD-10 codes for many common illnesses seen in a Primary Care practice.

Finally, we’ve posted a new presentation on ICD-10 Guidelines.  This brief, physician oriented presentation will help providers understand the rules of ICD-10, where to find them, and why they must be followed.  It shouldn’t take any more than 20 minutes to go through, but provides a wealth of information to help you choose the correct ICD-10 code. 

For all of you who have asked---yes, the Risk Score Calculator will be updated for 2016 payment year.  We’re in the midst of doing that now, and hope to have it available right after the first of the year.  

As always, if you have suggestions for tools for HCC University, please let me know. 

If you have coding questions, please contact us at Coding@scanhealthplan.com.

Happy Holidays all!  And a wonderful 2016!

Best,

Stacey

New Video on Roadto10.org

CMS has published a new, post implementation video on their website, Roadto10.org.  Per the announcement:

In this Centers for Medicare & Medicaid Services (CMS) ICD-10 video, Sue Bowman from the American Health Information Management Association (AHIMA) and Nelly Leon-Chisen from the American Hospital Association (AHA) discuss the unique characteristics and features of the ICD-10 coding system. Topics include:

• What is a valid code
• Guidelines for coding and reporting
• Coding process and examples: 7th character, unspecified codes, external cause codes, laterality
• How to submit coding questions
• Resources for coders 

Visit the Medicare Fee-For-Service Provider Resources webpage for a complete list of Medicare Learning Network resources on ICD-10.