Are Doctors Required to Use Words Rather than Codes?

The distinction is semantic: recommendations versus required.

It can be easy to lose sight of the difference between a “recommendation” and a “requirement.” But the distinction is key; requirements can necessitate refunds, while recommendations cannot.

The credit for this article goes to Alli, who reached out to me on this topic and analyzed it perfectly. Someone in her organization asserted that it is improper for a physician to “merely” record the ICD code to support a diagnostic test. According to this individual, there is a requirement that some text describe the diagnosis; a code by itself isn’t sufficient. To support this position, the individual submitted a pair of questions and answers from the American Hospital Association (AHA) Coding Clinic. 

Here is a slightly shortened version of that Coding Clinic exchange: 

The question read like so. “Since our facility has converted to an electronic health record, providers have the capability to list the ICD-10 CM diagnosis code instead of a descriptive statement. We are seeking clarification as to whether there is official policy or a guideline requiring providers to record a written diagnosis in lieu of an ICD-10-CM code number.” 

The response was “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,” the response continued. “It is not appropriate for providers to list a code number or select a code number from a list of codes in place of a written diagnostic statement. While we are aware that some payers may allow submission of code numbers on lab orders, Coding Clinic recommends that physicians provide narrative diagnoses/signs/symptoms as a reason for ordering the tests.”

Let’s look at the sleight of hand that occurred in that query and response. The question dealt with whether there were any official policies or guidelines. The response opened by claiming that there are regulatory and accreditation directives, but then fails to cite a single one. Instead, it ends with the very mushy reference to a “recommendation” from Coding Clinic. Let’s be clear: those are not the same. I recommend you get eight hours of sleep every night, and I recommend you eat five servings of fruits and vegetables a day, but those recommendations are most certainly not requirements. 

Coding Clinic should know better than to conflate them. I can’t say with 100 percent confidence that there are no relevant rules. It is impossible to prove a negative, and I don’t know what I don’t know. But I am not aware of any requirement that words be used to describe the diagnosis. More importantly, I don’t trust someone’s claim that there is a rule unless they include a citation to it. I believe that the reason Coding Clinic didn’t include a citation is that none exists. There’s a requirement for a physician to provide a diagnosis, but a code is a diagnosis. Whether the professional uses the numerals alone or includes the words for which the code serves as shorthand, the professional has provided a code. 

To drive this home, I’m going to rely on Tommy Tutone. If someone says “I need a way to reach Jenny,” can I say the digits 867-5309, or must I include some words? The answer doesn’t require prestidigitation. If someone wants to claim there is a rule, they’ve got to give me something I can hold on to. The code is enough; no words are necessary.   

Programming Note: Listen to David Glaser’s “Risky Business” reports every Monday on Monitor Mondays, 10 Eastern.