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Provider documenting ICD-10 codes in lieu of text definition

  1. #1
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    Default Provider documenting ICD-10 codes in lieu of text definition
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    I have a NeuroPsych Provider that documents the actual ICD-10 code on testing reports in lieu of a text definition. I think I read something from CMS a few years back about this, and I believe it said that the actual text definition must be in the note. However, I have been searching for this guidance and cannot find anything. Do any of you have an official guidance on this?

    Much appreciated!!
    Bridgette Martin LPN, CPC, CEMC, CGIC

  2. #2
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    You can find this in your ICD-10 code book, in the Official Guidelines for Coding and Reporting, Section I A (Conventions for the ICD-10-CM) under Code assignment and Clinical Criteria, where it states: "The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists." Obviously, if there is no diagnostic statement, then there can be no ICD-10 code choice on which to base it or validate it.

    Explain to your provider that an ICD-10 code is not a diagnosis, it is a classification, just as a Dewey decimal number is a classification for a group of topics of books in a library. Some ICD-10 codes may represent multiple different actual diagnoses. It is not clinically appropriate to use a code in place of a diagnosis, because it is not a diagnosis.
    Last edited by thomas7331; 08-17-2018 at 08:57 AM.
    Thomas Field, CPC, CEMC

  3. #3
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    Quote Originally Posted by thomas7331 View Post
    You can find this in your ICD-10 code book, in the Official Guidelines for Coding and Reporting, Section I A (Conventions for the ICD-10-CM) under Code assignment and Clinical Criteria, where it states: "The assignment of a diagnosis code is based on the providerís diagnostic statement that the condition exists." Obviously, if there is no diagnostic statement, then there can be no ICD-10 code choice on which to base it or validate it.

    Explain to your provider that an ICD-10 code is not a diagnosis, it is a classification, just as a Dewey decimal number is a classification for a group of topics of books in a library. Some ICD-10 codes may represent multiple different actual diagnoses. It is not clinically appropriate to use a code in place of a diagnosis, because it is not a diagnosis.

    Very good way to word that. I knew about the guideline in the ICD-10 book, but I guess I couldn't see the forest for the trees there. I kept looking for something that said 'you can't do this'.
    Thanks!
    Bridgette Martin LPN, CPC, CEMC, CGIC

  4. Default Diagnosis documentation
    Quote Originally Posted by bridgettemartin View Post
    Very good way to word that. I knew about the guideline in the ICD-10 book, but I guess I couldn't see the forest for the trees there. I kept looking for something that said 'you can't do this'.
    Thanks!
    Here is what I usually reference: Coding Clinic, First Quarter 2012, "Yes, there are regulatory and accreditation directives that require providers to supply documentation in order to support code assignment. Providers need to have the ability to specifically document the patient's diagnosis, condition and/or problem. Therefore, it is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement."


    Though this addressed ICD-9-CM, it is valid still.

    Hope that helps,
    Cindy

  5. #5
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    Quote Originally Posted by Cynthia Hughes View Post
    Here is what I usually reference: Coding Clinic, First Quarter 2012, "Yes, there are regulatory and accreditation directives that require providers to supply documentation in order to support code assignment. Providers need to have the ability to specifically document the patient's diagnosis, condition and/or problem. Therefore, it is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement."


    Though this addressed ICD-9-CM, it is valid still.

    Hope that helps,
    Cindy
    yes. thanks!!
    Bridgette Martin LPN, CPC, CEMC, CGIC

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