Now that many practices use sensitive ICD-10-CM coding software that allows clinicians to use drop-down menus to assign specific diagnosis codes, some doctors are asking whether they still need to provide a descriptive diagnostic statement in the patient’s record in addition to the ICD-10 code.
Quick answer: Yes. “ICD-10-CM is a statistical classification, per se, it is not a diagnosis,” points out the AHA Coding Clinic for ICD-10 (Fourth Quarter 2015 issue), regarded as an authoritative ICD-10 coding source.
“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,” Coding Clinic states.
For example, some ICD-10 codes may cover more than one clinical diagnosis and don’t adequately convey a patient’s specific condition. “Also, some diagnoses require more than one ICD-10-CM code to fully convey a patient’s condition,” explains Coding Clinic.
And, what if the doctor’s finger slips and he or she selects an incorrect code – there would be no narrative diagnosis to check it against.
“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,” reminds Coding Clinic.
In addition, while some payers (including Medicare) require ICD-10-CM diagnosis codes on lab orders, Coding Clinic recommends that these be supported by a physician’s documentation of narrative signs, symptoms or conditions.