Wiki Dx "codes" vs. "written" Dx's in notes

[nolagirl]

Does anyone out there have providers who use Dx "codes" in their progress notes as opposed to using "written" diagnoses? I think this is unacceptable documentation. I'd appreciate hearing other points of view. Thanks!

 

[sbicknell]

Wording only is acceptable
ICD-9 with wording is acceptable
ICD-9 only is not (good for superbill but not for documentation)

The physician should document his findings and diagnosis. The coding is only a method to capture these diagnoses statements by a numerical method

Here is an example of why not......
786.59 is defined as "other chest pain" in the tabular

In the index chest pressure, chest discomfort, atypical chest pain all code to 786.59

So if he only writes 786.59, in the note, which descriptor is chosen for that patient. How will other physicians in the practice know and how would a referring or consulting physician know

 

[nolagirl]

Thanks! I couldn't agree with you more!