Wiki Using icd 9 codes in assessment!


San Antonio, TX
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I have a client doctor using icd 9 codes in his assessment instead of writing out the diagnosis. It is my understanding this is not allowed if audited. Is that correct and if so, where can I find in writing he can't do that?
the answer is simple and complex, while there is nothing absolute in writing that prohibits this the fact is the codes are updated as ofter as semi annual and we could be going to say ICD-12 in 5 years or so, so 5 years from now when ICD-9 is long forgotten who is going to know what that dx code represents, and accurately, you will be scrambling around looking for a book to try and figure it out. So lets see how many offices have and ICD-8 book still around? What if you had to look back in a chart due to some absolutely necessary research for a patient into the family records and all you saw were ICD-8 codes, how would you figure out the diagnosis?
As all of us in the field know there are many gray areas in coding. This might be better posed to the physician as "not in agreement with industry standards" or "medical record integrity" vs providing a hard fast rule. Not everything we do has a policy written somewhere. This is more of a risk assesment outcome that requires internal policy for compliance and comprehensive protection to your practice and providers in the event of an insurance audit, malpractice case, auto accident, WC, the list could go on.

I am not sure what type of practice/facility you are working for but I would take the following steps before presenting your case:

* I would verify what your practices written policies are (if any) on documentation, coding, billing/compliance manual etc.
* If there is no policy maybe discuss creating one for compliance and defensible coding and present this as a protective compliance measure to the providers and practice.
* Use comparative documentation to point out the difference of how the other providers are documenting in your practice (i would ask permission from other providers to use their work as a comparative example). Come from an angle of consistency being important amongst the group in the event of an audit or supeona etc.

While us coders know these are important requirements it is important to think through the approach and language when dealing with your providers and their vast personalities :)

Good Luck!
Legal document

My major concern with this practice is that this is a legal document. Should it ever be used in court, could you really submit as testimony the patient is diagnosed with 401.9??? I have instructed MD's to not write out just codes - if they insist, at least write out a diagnosis or procedure. Haven't had pushback on that advice.