Wiki coding conditions documented on progress note

[warrenfamily103@gmail.com]

Hello everyone,

I am needing help with something... one of my providers stated that they can document something on the progress note but not code it out. Is this accurate? We are on paper charts still and on our encounter form they either circle or write in diagnoses. I then compare to the chart and code out correctly. If something isn't on the encounter, but is on the progress note, how should that be handled? When auditors review the records, if they see missed coding opportunities, will that reflect negatively on me as a coder, looking like I missed something? I don't know exactly how to approach this. Any guidance would be greatly appreciated.

 

[thomas7331]

You are correct - it's a basic guideline (which you can find in the ICD-10 official guidelines) and tenet of correct coding that code assignment has to be based on the provider's documentation in the patient's record, not on an encounter form. An encounter form is an administrative tool that office use and it isn't considered part of the medical record. No auditor is going to rely on what was circled on that form to make a determination as to whether or not a claim was coded correctly. If it's your job to look at the chart and code it correctly, and you see diagnoses or conditions documented that are relevant to the encounter but that were not put on the encounter form, then you are correct in adding these to the claim.

 

[warrenfamily103@gmail.com]

Thank you so much for the clarification! Can I ask where exactly is that stated in the guidelines? I looked over my book and I'm not seeing anything specifically stating that; and I know my providers will probably want to see something...I have the AMA codebook. I appreciate it!

 

[thomas7331]

Thank you so much for the clarification! Can I ask where exactly is that stated in the guidelines? I looked over my book and I'm not seeing anything specifically stating that; and I know my providers will probably want to see something...I have the AMA codebook. I appreciate it!

The official guidelines on diagnosis code assignment are from ICD-10 - you can find them in the front of the ICD-10 book or online at the CMS or CDC websites.

From Section I.A.19:
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient.

From Section IV.J:
Code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.