Wiki Physician Office Coding Question Regarding Diagnosis Capture From HPI

[tlpickard]

Hello,

I work for a physician practice as a certified coder, and we are currently receiving pushback from our CDI team regarding diagnosis capture within outpatient documentation.



The CDI team is advising that coders should only capture diagnoses documented within the Assessment & Plan section of the note and should not code from any other section of the provider documentation. My understanding has always been that coders may review the entire authenticated provider note and capture diagnoses that are clearly documented and clinically supported, as long as the condition was assessed, monitored, evaluated, treated, or otherwise addressed during the encounter.



For example, within the HPI, the provider documents:

“CKD stage 3, not at goal,” reviews lab results, and instructs the patient to follow up with nephrology.



The CDI team is stating that this cannot be coded because it is considered “history of” since it was not specifically listed within the Assessment & Plan section.



My question is:

For outpatient physician coding, are coders limited to assigning diagnoses only from the Assessment & Plan section, or can diagnoses documented elsewhere within the authenticated provider note (such as the HPI) be captured when documentation supports active evaluation/management of the condition?



I would appreciate any official guidance, coding clinic references, AAPC guidance, or best practice recommendations regarding this topic.



Thank you.

 

[jkyles]

For outpatient physician coding, are coders limited to assigning diagnoses only from the Assessment & Plan section,

No. Many people say this is best practice for documentation purposes, making the coder's life easier and audit defense. Many organizations have it as an internal policy. But I have never seen an official rule or policy that dictates where information about the diagnosis can, or cannot, be located in the note. Have you asked the CDI team to produce official guidance that supports its position?

 

[Pam Warren]

If it's a physician's statement within the note, you can code it. There is no regulatory guidance that says the diagnosis has to come from the assessment and plan. HCC coding is a bit different, however. The pulled-over chronic problem list has to meet the MEAT criteria in order to code. That's generally included in the Assessment, but if it was addressed in the history, you can code it.

 

[Birdie625]

IF a pt in a RHC / ACO setting sees Dr for a preop for THA (for OA) and has CKD (3a) and HTN documented, etc (MEAT aspect), what should be the order of dxs listed on the claim form. I would think Z01.818 / M16.11 / I12.9 / N18.31. Our software automatically re-ordered them to be: Z01.818 / N18.31 / M16.11 / I12.9. The ins is a Medicare HMO type / RHC claim = UB type form. System will not allow to re-order; it pushes all HCCs to top of diagnosis section when coding.
I dont know much about the HCC coding but did take some courses on such and I recalled it saying Coding rule would take precedence. Under N18 is a "code first" (HTN) / under I12 is a "code also". The system (Cerner) was recently 'updated' and is now pushing ALL HCCs to top of diagnosis list; even if being MEAT, those may not have necessarily been the actual reason for why pt is being seen. It freaks me out a bit to know all these types of claims are going to have the HCCs upfront. Also, I understand that the 'location' of the HCC does not matter as long as it was captured on the claim form itself. ie - if UB claim has 18 (? ##) diagnosis spots, the HCC could go in location 1-18 and still be captured by insurance (???).

I inq. w/another coder and Mgr and the coder replied ---
******There is not a rule that diagnosis go in a certain order for outpatient. While it is most appropriate to code the reason being seen primary, in this case N18.31 is a chronic illness that will influence how the doctor manages the patient’s care.

If the Pre Op was not primary, then the I12.9 would go before the N18.31, but since the Preop is primary, HCC codes for chronic conditions go next and then others.********

Can someone please explain? Thanks.