Wiki Documentation of CPT's/ICD-10's within a visit/procedure/operative note

[maryir]

I have a dilemma. I can't locate CMS,OIG or, Noridian (intermediatory) guideline regarding the documentation of CPT's/ICD-10's within a visit/procedure/operative note (posted by provider or electronically). Management/Compliance at my facility is stating, although not preferable, it's not a compliance or HIM issue. I've been able to locate articles (Codapedia and K Zupko) stating it's a compliance issue but again, I've not been able to locate a reference or policy from any authority.
I'm hopeful someone has the information I'm searching for.
Thank you

 

[amyjph]

I don't know that there are any guidelines or actual policies. I have had this same discussion with providers who insist on listing (incorrect) CPT codes in the header of an operative report. When it is coded and billed the codes don't match. What it does is open up an opportunity for an auditor or payer to deny the claim due to the documentation not matching or something such as that. It's just a bad idea. A code is not "written" documentation. You can't just say, the patient has M17.0... and not actually state it for example.

I would try and find denials/audits on these type reports as compared to providers who did not do this to show them.

 

[kdlberg]

There is nothing that says "a provider can't include codes in the documentation." But they can't just say "patient had catheter placement 36011." They have to include the full description of the procedure. As a coder, your obligation is to code to the narrative, not what the doctor thinks is the correct code. If there is no narrative, that's a problem.

This is from Coding Clinic 4th quarter 2015. Even though this addresses ICD-10 codes, I think the principle still applies.

"It is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement. [emphasis mine.] ICD-10- CM is a statistical classification, per se, it is not a diagnosis. Some ICD-10-CM codes include multiple different clinical diagnoses and it can be of clinical importance to convey these diagnoses specifically in the record. Also some diagnoses require more than one ICD-10-CM code to fully convey the patient's condition. It is the provider's responsibility to provide clear and legible documentation of a diagnosis, which is then translated to a code for external reporting purposes."