Wiki Director/Coder, HIM

[Deborah Evans]

Patient came into the ER with chronic pancreatitis. My ER coder assigned K86.0 along with the other alcohol related codes. 3M Nosology edit says "Code also exocrine pancreatic insufficiency (K86.81) when reporting code K86.0". ER physician did not document this diagnosis in his notes. With the term "code also" and not "code also if applicable", is it appropriate to assign K86.81 without physician documenting this?

Thanks in advance for any input on this.

 

[smoore123]

The ICD-10CM guidelines state the following:

17. “Code also” note
A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.

 

[Deborah Evans]

Thank you for the feedback. I should have researched further. I did not feel comfortable adding that code without documentation but the claim is being denied and was wondering if this could have been the reason. Thank you again. This was the first time I used this forum and it was gratifying to have someone answer so quickly. I will definitely be using this again.

Deborah