Wiki Would you consider this a diagnostic statement?

[Queizati]

There is a debate we are having with the billers and coders.

Those who are familiar with this EMR (or EMRs in general), may know that when a physician selects an ICD-10 code for a visit, that code and its descriptor will then display in various areas in the EMR. Would you consider this a "diagnostic statement" as per the ICD-10 guidelines to code a diagnosis from, despite it not being in the body of the progress note and despite the assessment and plan diagnosis not aligning with the chosen ICD code(s)?

As you can see in the first image, highlighting the ICD-10 descriptor shows the associated diagnosis codes selected by the physician.

The billers say we can use the ICD-10 descriptor generated by the EMR to assign a code but the coders feel the coding should be done by what is stated by the physician within the progress notes.

What would you do?

 

[sls314]

The physician needs to state the diagnosis.

I would absolutely not use a descriptor generated by the EMR in place of a physician documented diagnosis.

 

[Queizati]

The physician needs to state the diagnosis.

I would absolutely not use a descriptor generated by the EMR in place of a physician documented diagnosis.

Thank you, I appreciate your input!

 

[amyjph]

The provider has to state in words what the diagnosis is. An alphanumeric system generated ICD-10 code is not a diagnosis in a medical record.
How would you answer your question, what did you think? I think you answered it yourself by this: "The billers say we can use the ICD-10 descriptor generated by the EMR to assign a code but the coders feel the coding should be done by what is stated by the physician within the progress notes." This is why you don't have billers coding. I have also seen billers just slap 59 and 25 on to, "bypass the edits"... scary.