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.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

David M. Glaser, Esq.

David M. Glaser is a shareholder in Fredrikson & Byron's Health Law Group. David assists clinics, hospitals, and other health care entities negotiate the maze of healthcare regulations, providing advice about risk management, reimbursement, and business planning issues. He has considerable experience in healthcare regulation and litigation, including compliance, criminal and civil fraud investigations, and reimbursement disputes. David's goal is to explain the government's enforcement position, and to analyze whether this position is supported by the law or represents government overreaching. David is a member of the RACmonitor editorial board and is a popular guest on Monitor Mondays.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

The Inpatient Admission Order: Master the Who, When, and How

The Inpatient Admission Order: Master the Who, When, and How

During this webcast Dr. Ronald Hirsch delves into the inpatient admission order process including when to get it, when it becomes effective, its impact on billing and payment, who can write it, how to cancel it, the effects on the beneficiary, and more. You’ll leave with a clear understanding of inpatient orders and guidelines for handling improper orders that you can implement immediately.

June 20, 2024
Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Michelle Wieczorek explores challenges, strategies, and best practices to AI implementation and ongoing monitoring in the middle revenue cycle through real-world use cases. She addresses critical issues such as the validation of AI algorithms, the importance of human validation in machine learning, and the delineation of responsibilities between buyers and vendors.

May 21, 2024
Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Optimize your inpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. Participants will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.

June 26, 2024
Advanced Inpatient Clinical Documentation Integrity: Harnessing Technology, Analytics, and Compliance

Advanced Inpatient Clinical Documentation Integrity: Harnessing Technology, Analytics, and Compliance

Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P., as she helps you navigate advanced inpatient CDI technologies, regulatory changes, and system interoperability. Angela will provide actionable strategies for integrating AI and predictive analytics into CDI practices, ensuring seamless system interoperability, and maintaining compliance with evolving regulations. Attendees will learn to select and implement advanced EHR systems and CDI software, leverage data analytics to enhance documentation accuracy, and stay audit-ready with the latest compliance updates. Real-world case studies and practical tools will empower you to drive continuous improvement in CDI, improve patient outcomes, and enhance organizational efficiency. Don’t miss this opportunity to advance your CDI practices and stay ahead in this dynamic field.

July 11, 2024
Foundations of Inpatient Clinical Documentation Integrity: Enhancing Accuracy and Compliance

Foundations of Inpatient Clinical Documentation Integrity: Enhancing Accuracy and Compliance

Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P, for an insightful webcast on improving inpatient clinical documentation integrity (CDI). Inaccurate documentation can lead to misdiagnosis, improper treatment, and compromised patient safety. High workloads, lack of standardized practices, and outdated EHR systems contribute to these issues, affecting care quality and financial outcomes. Angela will offer practical strategies and tools to enhance accuracy, consistency, and timeliness in documentation. Attendees will learn to use standardized templates, checklists, and advanced EHR systems, while staying compliant with regulations. Improve patient care, ensure accurate billing, and reduce audit risks with actionable insights from this essential webcast.

June 26, 2024
Mastering E/M Coding: Navigating the Evolving Landscape

Mastering E/M Coding: Navigating the Evolving Landscape

Join industry expert, Kathy Pride, RHIT, CPC, CPMA, CCS-P, for an in-depth exploration of Evaluation and Management (E/M) coding, tailored for healthcare professionals navigating recent guideline changes. Dive into advanced topics beyond mere code selection, including shared visits, criteria for selecting E/M levels, and documentation best practices. Gain clarity on complex guideline terminology and ensure compliance with regulatory standards. This comprehensive session is essential for coders, auditors, educators, and practitioners seeking to enhance their proficiency in E/M coding and maximize revenue capture.

June 19, 2024

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

Honor Memorial Day with Savings! Get 20% off all items using code MEMORIAL24 at checkout. Shop today and save! Offer valid until May 31. Exclusions apply.

Happy World Health Day! Our exclusive webcast, ‘2024 SDoH Update: Navigating Coding and Screening Assessment,’  is just $99 for a limited time! Use code WorldHealth24 at checkout.