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Question: What diagnosis information can I code from documentation recorded by staff other than the patient’s physician?

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Answer: According to FY 2027 ICD-10-CM Official Guidelines for Coding and Reporting, there are some situations where code assignment can be based on documentation from clinicians (healthcare professionals who can add documentation to a patient’s official medical record, according to regulations and/or accreditations) other than the patient’s provider, including body mass index (BMI), depth of nonpressure chronic ulcers, pressure ulcer stage, coma scale, stroke severity according to the National Institutes of Health (NIH) stroke scale (NIHSS), social determinants of health (SDOH), laterality, blood alcohol level, underimmunization status, and firearm injury intent.

While such information may be documented by other healthcare professionals, the associated diagnosis “must be documented by the patient’s provider” and if there’s any conflicting information in the medical record, the patient’s provider should be queried.

For example, if a physician diagnoses a patient with a pressure ulcer, a coder would need to know the stage of the injury to select the correct code. With the physician’s diagnosis of a pressure ulcer in the documentation, a coder would be able to use the documentation provided by a wound-care nurse describing the pressure ulcer stage to ultimately select the correct code, even though the wound-care nurse isn’t the patient’s physician.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC