ICD-10-CM OGs: Get Team In Sync on Coding Based on Provider’s Statement

team discussion improves medical documentation and coding

ICD-10-CM Official Guidelines state that your choice of diagnosis code is based on the provider’s diagnostic statement, but that’s not always as clear-cut as it sounds. Let’s dig in to this guideline.

Work From the Official Guideline Wording

The 2019 ICD-10-CM Official Guideline (OG) we’re discussing here is 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.

In other words: Coding is based on provider documentation because the provider (not the coder) is the one responsible for diagnosing the patient. So far, so good.

So What’s the Problem?

Confusion may set in when it appears that the documentation for the case does not support current clinical criteria for the diagnosis that the provider records.

As a coder, your starting point should be this: “While physicians may use a particular clinical definition or set of clinical criteria to establish a diagnosis, the code is based on his/her documentation, not on a particular clinical definition or criteria.” This quote is from AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS (2016, vol. 3, no. 4).

That Coding Clinic article goes on to give the example of sepsis. If the doctor documents sepsis, you should report the ICD-10-CM code for sepsis regardless of whether the diagnosis is based on new clinical criteria, old clinical criteria, personal judgment, or something else.

Don’t miss: That Coding Clinic also states that if a clinical validation reviewer later disagrees with the provider’s diagnosis that you coded, that is not a coding error. That is a clinical issue.

Remember the flip side: “Coders shouldn’t be coding sepsis in the absence of physician documentation because they believe the patient meets sepsis clinical criteria,” the Coding Clinic article states.

Add Another Example to the Mix for Better Understanding

Here’s another example. This one is from Coding Clinic (2018, vol. 5, no. 4). The question was whether it was appropriate to code morbid obesity when an anesthesiologist documented morbid obesity for a patient with a body mass index (BMI) below 40. There was no other documentation about obesity in the record.

The response in Coding Clinic was that you should report E66.01 (Morbid (severe) obesity due to excess calories) in this case. The reasoning was that BMI is a screening tool only, and a patient’s BMI should not be the coder’s deciding factor on whether to code obesity. You should assign obesity based on provider documentation of obesity.

Side note: While we’re on the topic of BMI, don’t forget this twist. BMI is one of the few exceptions where the OGs allow code assignment based on documentation from clinicians who are not the “physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis.” This is because others, such as a dietitian, often document BMI. The physician/qualified practitioner still must be the one to document the related diagnosis, such as obesity, though. You’ll find this information in I.B.14.

Plan Ahead for Problem Cases

To sum up, the basic rule for the coder is to assign codes based on the provider’s diagnostic statement. But the real world isn’t always so straightforward. Consider the case of an experienced coder who has been working in a specialty for many years. If she can’t follow how a doctor got to the final diagnosis based on what’s documented, then it’s possible an auditor for a payer won’t be able to follow it either. And in that case, the auditor may determine that payment was inappropriate, meaning the payer will demand the money back. Such documentation is likely to be a problem in legal cases, too.

Consequently, it is to an organization’s advantage to have a clear process for handling documentation that seems to not support the final diagnosis. Each person’s role should be clearly defined, including coder, documenting provider, and possibly a provider assigned to be the reviewer in such cases. Additionally, documentation training can address specific weak areas that have been seen. Some examples may include making sure the record states why certain diagnostic criteria may not be relevant to the specific case, and spelling out the review of labs and other tests in the context of the patient’s personal health status.

Final note: If the coder thinks the diagnosis is clearly wrong, that’s another issue all together. For instance, if the documentation shows a right toe fracture and the record indicates the patient has had his right leg amputated, then it’s time for a query.

What About You?

Has your organization discussed this ICD-10-CM Official Guideline and what it means for documenting and coding diagnoses?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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