Wiki Who can assign ICD-10 codes?

[cayoung]

I have been instructed that CMS only allows the physician to assign ICD-10 codes for his/her service. Is this accurate? If so, would you be able to share your reference?

 

[CodingKing]

I have been instructed that CMS only allows the physician to assign ICD-10 codes for his/her service. Is this accurate? If so, would you be able to share your reference?

There is no rule from CMS that I have seen. There isn't even a rule that you need to be certified to code (most states). The physician just needs to put the diagnosis statement in their own words. Obviously you can't diagnose the patient on your own (no change there).

The only thing you will find new about assigning diagnosis codes is in the 2017 ICD-10-CM guidelines that just clarifies that you cant make a diagnostic conclusion on your own. For instance if Dr puts states the patient has the common cold but you think the documentation supports the Flu, you have to code for the common cold as that is what the physician diagnosed. Nothing changed about querying the MD if the diagnosis doesn't make sense or they need to add additional information to apply the correct DX.

I.A.19 - Code assignment and Clinical Criteria
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

diagnosis codes, diagnosis coding