Wiki Changing provider ICD10 selections

[lcourt6]

Hi all. There is a discussion within the organization that I work on changing provider ICD10 selections. The discussion is questioning if a coder sees that the provider has documented a more specific code (like E11.42) based on their documentation but selected a simpler code for billing (like E11.9) can it be changed to the more specific code? I understand that this is possibly up to each organization to decide (personally I would query the provider), but is there any documentation around what a coder can do and what certifications allow them to make those changes?

 

[thomas7331]

The ICD-10 guidance, per the official guidelines in the book, is that "assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists". In my experience, it does not matter what code a provider has selected - what matters is that the code submitted on a claim is supported, in documentation, by the providers statements. Codes must be correctly assigned according to ICD-10 guidelines based on that narrative in the record. The organizations where I've worked have always allowed coders to change a provider's selected code to bring it into alignment with what the documentation supports.

As far as what certifications are required - that is, as you've mentioned, up to the organization to decide and there are no official rules that require certification in order to assign codes. Payers and auditors are generally not concerned with what certifications the providers' employees have - they are only concerned that the codes submitted are correct and supported by the documentation.

 

[Lyta2000]

I agree that the diagnosis submitted should be supported by the documentation. The narrative must be used to choose the diagnosis code.

As to whose job it is to change a diagnosis code - that is based on the policy of your department and organization. I am an auditor and I can change any code if it is incorrect and request charge corrections. I then notify and educate the MD. Follow the department policy and processes for how to handle.