ICD 10 Coding Alert

When your provider’s documentation falls short, approach them with official guidelines and confidence.

Sometimes an encounter summary does not match the diagnosis codes in the progress note, and it creates a discrepancy in the patient’s medical record that can lead to medical errors, insurance claim denials and, if done repeatedly, legal issues.

For example, when a provider has a diagnosis that doesn’t meet reporting criteria — for example, the encounter summary shows F10.280 (Alcohol dependence with alcohol-induced anxiety disorder), but there is no mention of anxiety in the progress note — it can be problematic.

Besides creating potentially fraudulent claims, poor or missing documentation that does not support a reported diagnosis can lead to patient harm. For example, if a provider leaves out details about a previous allergy diagnosis, the patient may receive medication they are allergic to because vital allergy information was never recorded in the encounter summary. Another example is when a patient with a cancer diagnosis fails to document a supporting follow-up action (biopsy, imaging, etc.) on an abnormal lab result’s encounter note, this could result in delayed studies and treatment.

Accurate and consistent provider documentation also plays an important role in risk adjustment and better patient care. Payers use the diagnosis codes submitted by providers on claims to identify what types of programs are needed for patients who are at greater risk of certain diseases.

Insufficient Documentation Is the No. 1 Cause of Improper Payments

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data report, the national accuracy rate for proper payments is 92.3 percent with improper payments at 7.7 percent. The common causes for improper payments by percentage include:

• Insufficient documentation: 59.9 percent
• Medical necessity issues: 15.7 percent
• Incorrect coding: 10 percent
• No documentation: 8.2 percent
• Other: 6.3 percent

The report has in-depth Medicare Fee-For-Service (FFS) statistical data as well as projected improper payments, upcoding, overpayment, and underpayment rates. They provide areas where documentation most commonly falls short.

Ensure the Diagnosis Is Confirmed in the Medical Record

The diagnosis must be confirmed in the medical record and must impact the patient’s care in some way to meet reporting criteria. Here are a few examples: If a condition is missing or documented as “suspected,” “probable,” “rule out,” or “working diagnosis,” it doesn’t meet the reporting criteria.

A query should be considered when the documentation:

• Is not specific enough for the ICD-10-CM choice, with information that is conflicting, incomplete, illegible, imprecise, ambiguous, or inconsistent.
• Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure.
• Describes or is associated with clinical indicators without a definitive relationship or link to an underlying diagnosis. For example, if documentation indicates the patient has diabetes mellitus and a common complication of diabetes, such as retinopathy, but has not indicated a link between the two. 
• Provides a diagnosis without underlying clinical validation. For example, missing test or imaging results confirming the diagnosis

Approaching the provider about insufficient documentation is not always easy because they are busy caring for patients. They may feel that spending time fixing documentation takes away from their time with patients. You may need to remind the provider that accurate diagnosis documentation paints the whole picture of the patient’s clinical story and promotes quality in patient care — but be sure to take caution before approaching them about their patient encounter note deficiencies.

Approach Your Provider With 7 Tactful Talking Strategies

Nobody likes difficult conversations, especially when it involves telling a provider they aren’t meeting the criteria to get paid for their services. Being tactful with your words will help diffuse resistance and any hard feelings your provider has. Here are some steps you can follow to approach the conversation with professionalism and resolution:

1. Prepare for the query: Before you query the provider, make sure you understand the diagnosis and why the reporting criteria doesn’t support it. Gather all necessary documentation and official guidelines to support your point.
2. Choose the right time and place: Find a time and place that is convenient for the provider to have this discussion and have the provider put it on their schedule. Avoid interrupting them, especially when they are busy with patients.
3. Be respectful and professional: Start the conversation by acknowledging the provider’s expertise and experience. Make it clear that your intention is to ensure accurate and compliant reporting, not to question their medical judgment.
4. Explain the issue clearly: Explain the diagnosis reporting criteria simply and why the documentation doesn’t meet them. Use the documentation and guidelines you gathered from official sources (CPT^®, ICD-10-CM, HCPCS Level II code books; National Correct Coding Initiative [NCCI] edits; local and national coverage determinations [LCDs and NCDs]; payer contracts; medical specialty societies; etc.) to support your point.
5. Listen to their perspective: Give the provider a chance to explain their reasoning. They may have information or insights that you weren’t aware of.
6. Offer a solution: Suggest a compliant way to modify the diagnosis verbiage, or include more detailed documentation to clarify medical necessity of services so that it meets the reporting criteria.
7. Follow up: After the conversation, send a follow-up email summarizing what was discussed and agreed upon. This can serve as a reference for both of you in the future and to prove compliant activity in the practice.

Remember: The goal is to ensure accurate and compliant reporting, not to challenge the provider’s medical expertise. By approaching the conversation with respect and understanding, you can foster a positive working relationship with the provider.

Michelle A. Dick, BS, Development Editor, AAPC