Wiki Using ICD-9 diagnosis codes rather than language

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colsonccsp@yahoo.com

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May a provider use the ICD-9 diagnosis codes on a document rather than use the words to describe the condition the patient has? For example if on an operative report for an epidural steroid injection the provider uses 724.4, 722.52, 724.8 as the pre and post op listed diagnoses. Nowhere on the operative report does it describe the diagnosis in anything other than codes.

If this is or is not allowed could you please point me to some official documentation that may be used to support the stance.
 
That isn't very good documentation quality. Although I doubt there's anything outside the Joint Commission standards, it is bad practice from a patient care standpoint. Although coders and billers may understand codes to be a universal language, not all health care providers are going to be familiar enough with the codes the extract the meaning. This could have implications on patient care outside the immediate future.
 
Thank you for responding,

Do you think this would stand under audit?

My point is that since it is not a diagnosis per-say it is a code for a diagnosis on audit CMS would not accept the record that way. My stance is not based on a actual document but from my opinion of what constitutes a complete record. I would like something official, hence the posting.
 
AHA COding Clinics and I am sorry I do not recall which issue although in a post on this forum it is stated, anyway they stated the numeric code should never be in the medical record document, the provider's diagnosis needs to always be narrative. Many providers do not use the specific diagnosis codes, and with ICD-10 CM just around the corner, if this were looked at in 2 years it is possible you would not know the exact diagnosis since there are several ICD-10 CM codes that have no equal in ICD-9.
2 of the listed codes are for other or unspecified conditions and without the actual diagnosis it is unclear as to whether medical necessity has been met, if it is coded correct or anything. As far as passing an audit, I cannot see that it will since there is no way to know the patient's actual condition.
 
Thank you! I will track down the coding clinic.


mitchellde said:
AHA COding Clinics and I am sorry I do not recall which issue although in a post on this forum it is stated, anyway they stated the numeric code should never be in the medical record document, the provider's diagnosis needs to always be narrative. Many providers do not use the specific diagnosis codes, and with ICD-10 CM just around the corner, if this were looked at in 2 years it is possible you would not know the exact diagnosis since there are several ICD-10 CM codes that have no equal in ICD-9.
2 of the listed codes are for other or unspecified conditions and without the actual diagnosis it is unclear as to whether medical necessity has been met, if it is coded correct or anything. As far as passing an audit, I cannot see that it will since there is no way to know the patient's actual condition.
Click to expand...
 
mitchellde said:
I believer it was 1st or second quarter 2012. might have been 2011.
Click to expand...

It was first quarter 2012, page 6, article titled "Code number in lieu of a diagnosis." What I found interesting is that the article states that there are "regulatory and accreditation directives" that require a narrative instead of a code number, but the article doesn't list them.
 
THANK YOU LANCE!!! I could not find the actual issue anywhere although i read it. If you are the subscriber it is easy to contact the coding clinic staff and request this. But do note that coding clinics are recognized as THE authoritative source of info on coding ICD codes.
 
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