Wiki May we use patients "words" for coding EMR?

[Brandy0618]

Good afternoon. I would like advise on whether we are able to code (attach diagnosis code) the patients words in CC/HPI in the clinical note? For example, if a patient tells the MA, LVN who rooms the patient that they are experiencing pruritis but the provider does not include pruritis in his/her note. Can we as coders denote L29.8 as one of the diagnosis codes linked to the anatomical region the patient reports itching? I run into this issue quite often and I have researched many areas for an answer but I have not found any. Thank you for any help. Happy Wednesday.

 

[thomas7331]

Good afternoon. I would like advise on whether we are able to code (attach diagnosis code) the patients words in CC/HPI in the clinical note? For example, if a patient tells the MA, LVN who rooms the patient that they are experiencing pruritis but the provider does not include pruritis in his/her note. Can we as coders denote L29.8 as one of the diagnosis codes linked to the anatomical region the patient reports itching? I run into this issue quite often and I have researched many areas for an answer but I have not found any. Thank you for any help. Happy Wednesday.

You can use the patients words' if they are documented by the physician or NPP, but not from the staff rooming the patient. With the exception of the codes as specified by ICD-10 that can be assigned from ancillary staff notes (e.g. codes for social determinants of health, stages of a pressure ulcer, BMI, etc.), all code assignments can only be based documentation by providers qualified to make a diagnosis.

 

[Brandy0618]

You can use the patients words' if they are documented by the physician or NPP, but not from the staff rooming the patient. With the exception of the codes as specified by ICD-10 that can be assigned from ancillary staff notes (e.g. codes for social determinants of health, stages of a pressure ulcer, BMI, etc.), all code assignments can only be based documentation by providers qualified to make a diagnosis.

Thank you for your help. I appreciate it.