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.
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.
