16 Feb Off
If I could change one thing in most Electronic Medical Record (EMR) systems, it would be to stop forcing the provider to choose a diagnosis code for each diagnosis or assessment. This was a great disservice, done with good intentions undoubtedly, as EMR vendors tried to kill the proverbial two birds with one stone, or with one code, in this case. Doctors and other providers are trained to write diagnostic statements that describe the conditions of the patient. When they are forced to mold these statements into and ICD-10 code description, the chance for coding error is high, and we see them often in our chart audits.
The reasons for this are simple. Doctors write diagnostic statements. Coders interpret those statements into a statistical classification scheme known as ICD-10.
I am gratified to know that the American Hospital Association’s Coding Clinic recently issued a statement agreeing with this view. In their Q4 2015 edition, the Coding Clinic reasoned that that multiple clinical diagnoses may be included in a single ICD-10 code, and it may be important to document these separate diagnoses. They also indicated the abbreviated ICD-10 code descriptions are often nonsensical as a diagnosis.
We commonly read Assessments that are a Coder-speak list of ICD-10 codes and descriptions, but hardly describe the actual clinical condition of the patient meaningfully. Just today, I read the following assessment for a comprehensive exam:
- DJD (degenerative joint disease) M19.90
- Essential hypertension I10
- Preventative health care Z00.00
- Renal colic N23
- Thyroid nodule E04.1
- Vitamin D deficiency E55.9
- Morbid obesity E66.01
- CKD (chronic kidney disease) N18.9
- Hyperglycemia due to type 2 diabetes mellitus E11.65
- Pain management Z51.89
- Low back pain M54.5
- Chronic abdominal pain R10.9
- Ureteral colic N23
- Renal stones N20.0
- MDD (major depressive disorder), recurrent, in partial remission F33.41
- HLD (hyperlipidemia) E78.5
- Splenic artery aneurysm I72.8
- Diverticulosis K57.90
- Social problem Z60.9
- Financial problems Z59.8
While this patient clearly has lots of problems, this “assessment” is composed of descriptions of codes (not diagnoses) that fall far short of describing the problems meaningfully.
We strongly favor Doctor-speak in a narrative description of sufficient specificity and strongly agree with the Coding Clinic conclusion that “It is the provider’s responsibility to provide clear and legible documentation of a diagnosis, which is then translated to a code for external reporting purposes.”
Some EMRs allow for additional narrative beyond the ICD-10 code and description. Kudos to providers that take advantage of that option. Or, better yet, leave the coding to coders and let providers choose how to write diagnosis statements that best describe their thinking about the patient’s condition.
If you, or your staff, need additional training to better understand and use ICD-10 coding, we are here to help!