When considering coding protocols, it’s vitally important to differentiate between “requirements” and “recommendations.”
In June I did a Monitor Mondays segment and a RACmonitor article discussing whether physicians are required to include words describing a diagnosis, or whether listing a code is sufficient. I was not able to locate any requirement in an authoritative source that physicians use actual words.
The idea for the article arose after a Coding Clinic Q&A addressed a query seeking clarification of whether there was an official policy or guideline on the subject. The response asserted that there were regulatory and accreditation directives, but it failed to cite a single one. This led me to conclude that while a text description of the diagnosis might me be superior, it was not required. Coding Clinic had made the far-too-common mistake of characterizing something as a requirement, absent any authority.
Fast forward to last week, when Chris Gallagher wrote a rebuttal under the headline “Yes, Doctors are Required to use Words.” The rebuttal tries to cut me some slack by saying that perhaps it was “taking what might have been meant as a light-hearted post too seriously,” but I am afraid that the rebuttal didn’t take the original article seriously enough. Gallagher made exactly the same mistake the Coding Clinic article did. Had she said, “there is no requirement, but it is still a good practice,” that would have been a fair point to make. I would even have agreed.
But the thesis of my article was that there is no REQUIREMENT that physicians use words, rather than a code. The rebuttal spends considerable time explaining what coding is and why coders are important. I don’t quibble with any of that. I did not, and would not, assert that coders are unimportant. I was explaining that there is no statute or regulation requiring the use of words rather than text. If Ms. Gallagher wished to attack that conclusion, her article should have included a citation to authority. It did not.
It’s important to remember that the only binding authorities for Medicare are the Medicare statutes, the regulations, National Coverage Determinations (NCDs), and, probably Centers for Medicare & Medicaid Services (CMS) rulings. To accurately claim that anything is “required by Medicare,” one must be able to cite at least one of those sources. While Ms. Gallagher may feel that words are preferable, recommended, or even demonstrably superior, that is very, very different than required. Statements from trade groups, lawyers, consultants, and even CMS officials are not binding authority.
On LinkedIn, the American Health Information Management Association (AHIMA) posted Ms. Gallagher’s article, and a number of coders jumped on the bandwagon, talking about a “requirement” for physicians to use words. Let me reemphasize this: there are real reasons that words may be preferable. A one-digit typo in a code number will be much harder to detect than a typo in a text description, for example. But many of the LinkedIn posts mistakenly claim to cite “binding” authority. LCDs got a chunk of attention. I didn’t spend time analyzing the LCDs, because they can’t change the discussion.
Let’s revisit the regulatory hierarchy. LCDs are not binding. While an organization may choose to follow an LCD, the federal regulations specifically allow an administrative law judge (ALJ) to disregard an LCD. In the Asceracare case, the court of appeals explained that a hospice is not required to follow an LCD’s definition of a terminal illness, explaining LCDs are not binding and should not be considered “the exact criteria used for determining terminal illness.” Coding Clinic is not a federal regulation. While it can say something is “not appropriate,” absent support from a regulation or NCD, citing to Coding Clinic is like citing advice from Dear Abby or Miss Manners. In other words, it might be polite or wise, but it’s not something required by law.
Sorting through situations like this is a challenge for any compliance program. On Aug. 24, RACmonitor will be hosting a webinar offering strategies for dealing with problems like this one. You may register HERE.
Programming Note:
Listen to David Glaser’s “Risky Business” segment, Mondays on Monitor Mondays, 10 Eastern.
Last week, one of my clients got a letter from a state Attorney General. The letter requested information about two of the organization’s former employees.
EDITOR’S NOTE: This is the third in a multi-part series on the Comprehensive Error Rate (CERT) study in which senior healthcare analyst Cohen describes how
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient 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 outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
The 2025 Medicare Physician Fee Schedule brings significant changes to payment rates, coverage, and coding for physician services, impacting practices nationwide. Join Stanley Nachimson, MS., as he provides a comprehensive guide to understanding these updates, offering actionable insights on new Medicare-covered services, revised coding rules, and payment policies effective January 1. Learn how to adapt your practices to maintain compliance, maximize reimbursement, and plan for revenue in 2025. Whether you’re a physician, coder, or financial staff member, this session equips you with the tools to navigate Medicare’s evolving requirements confidently and efficiently.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
Copyright © 2025 RACmonitor. Powered by MedLearn Media.
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 →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
