Monday, January 2, 2017

Connecting the dots: Diagnosis, Procedures, Documentation

Connecting the dots: Diagnosis, Procedures, Documentation

Originally published on 07.30.2016
Lori-Lynne A. Webb 

In the outpatient setting, we have a different set of “rules” to follow in regard to the official guidelines for coding and reporting in ICD-10cm than those that follow the guidelines for “inpatient” care.  The ICD-10cm guidelines for outpatient coding are followed and are used by hospitals/providers for coding and reporting hospital-based outpatient services, and provider-based office visits.  In addition, the terms “encounter” and “visit” can be used interchangeably.  As a reminder, the guidelines for outpatient coding are different from inpatient coding in the fact that the term “principle diagnosis” is only applicable to inpatient services; as are the coding of probable, suspected, rule outs and inconclusive. 

For those who code outpatient or office based services; instead of reporting a “principle” diagnosis, you would code the first-listed diagnosis, as well as signs and symptoms that are documented by the provider of care.  In some cases, it may take more than one visit or encounter to arrive at and/or confirm a specific “diagnosis”.  ICD-10cm guidelines allow us to continue to report signs and symptoms over the course of the outpatient workup.    The majority of the signs and symptom codes are found in Chapter 18 of the ICD-10cm diagnosis codes, however, other signs and symptom codes can be found in many of the other sections and chapters of ICD-10cm.

When assigning an ICD-10cm diagnosis code for an outpatient surgery, or same-day surgery, it is appropriate to code the “reason” for the surgery as the first listed diagnosis (eg reason for the encounter).  When  coding for an outpatient hospital observation stay, it is appropriate to code the current medical condition as the first-listed diagnosis.  (eg.  pregnant patient with decreased fetal movement) , In addition it is appropriate to code for all additionally documented conditions.  If the patient has chronic diseases noted, the chronic disease or chronic disease status may be coded in addition to the primary “reason” the patient is seeking treatment, but only if the physician documents the chronic condition is impacting the current care or medical decision making of the presenting problem or illness. 

Diagnosis codes are to be used and reported at their highest number of characters available and specificity.   However, sometimes all we have to go by is the documentation of the “signs and symptoms” that the provider of care has documented.   If the provider has not referenced a clinical significance to complaints or ill-defined symptoms, we have to code it as a “sign or symptom” from the ICD-10cm codeset.  It is the providers responsibility to clearly document the patients’ diagnosis.    

Coders are not allowed to “infer” or code directly from an impression on diagnostic reports such as an x-ray, ultrasound, or pathology report.     In the outpatient setting, the provider of care must confirm the diagnosis in the body of the patients’ visit note, procedure /operative note, or progress note.   An example of this is; In the provider notes, the documentation states the patient has an “elevated blood pressure” of 160/90.  As a coder, this does not mean the provider has diagnosed the patient with hypertension, it simply means that today, the patients’ blood pressure is elevated.   However, if the provider  notes that the patient has an “elevated blood pressure of 160/90 today, and will begin treating for hypertension; the coder can code the specific “hypertension” diagnosis rather than the ‘signs and symptom” code of elevated blood pressure.     If the coder does not have more specific information than “hypertension” written in the record; a query to the provider is in order to get the most specificity for coding clarity, and good clinical documentation for the overall quality of medical care.

When assigning codes for an outpatient or ambulatory surgery case, code the diagnosis for which the surgery was performed.  However…. If the post-operative diagnosis is different than the pre-operative diagnosis listed by the surgeon, then code what is reported as the post-operative diagnosis.  In reviewing or auditing an operative record, the surgeon should give both diagnoses.  The rule of thumb, is the coder will defer to coding the diagnosis based on the post-operative notation, or most definitive clinical documentation recorded in the patients’ medical chart. 

When coding a diagnosis for and ambulatory or same-day surgery, the urge to rely on the absolute information from a pathology report can be hard to resist.  As coders, we have been trained to hold or delay submitting the insurance claim pending more information from a pathology report.  Pathology reports contain great information as to sizes, weights, measures, cell types, malignancies, infections, and even more extensive clinical information than is normally reported in an operative/procedure record.

However, within the guidelines of coding, coders should not assign codes based on the pathology report, unless the physician has confirmed the diagnosis within their operative, procedure, or progress notes.   For example, if the physician notes within the documentation the removal of a “breast lesion/mass” and the pathology record documentation  states “breast carcinoma”, the coder should not code a “breast carcinoma” until the surgeon clarifies or adds this additional information from the pathology report to the operative and/or progress note. 

Pathology reports certainly help us paint the picture to good coding standards, but sometimes do not “help” as much as they can “hinder” the true picture.   When coding for a lesion removal with CPT codes, understanding how lesions are measured, is vital to good documentation of the procedure.  According to the CPT manual guidelines the measurements of the lesion need to include the size of the lesion itself, and include the margins needed for medical necessity prior to excision. 

As part of good clinical documentation, the provider should document and include an accurate measurement of the lesion itself, and the margins to be included.  If the coder relies on only the pathology report,  it may not be an accurate sizing.  Unfortunately when excising specimens, it is common to have the procured tissue “shrink” or the specimen may be “fragmented” upon receipt to the pathology department.  Measurement of the defect size post excision may also be incorrect, as the excision site may “expand” once the tissue has been incised or excised.  Either way, this leads to incorrect documentation and incorrect coding. 

The documentation bottom line is this:
• Measurement of the lesion plus the margins should be made prior to the excision
• Pathology reports should not be used in lieu of physician documentation
• Query the physician regarding the size of the lesion as well as the margins excised if not clearly noted in the operative/procedure note.

Below is a copy of a very generic type of lesion excision query form you can use to communicate to your provider the information you need to accurately code the encounter:


Patient Name: ________________________ : DOB:________________
DOS: _____________ MR #:_________________

Query Date:________       Requested by: _____________

Documentation clarification is required to meet medical record documentation compliance, medical necessity, and accuracy of diagnosis and procedure coding.

In the medical record/operative procedure note, the following information is needed to assign the correct ICD-10cm and CPT code(s). Please provide the following:

o  SIZE of the greatest clinical diameter in centimeters plus margins for each lesion excised

o  DEPTH of the tissue involved for each lesion (e.g., skin, fascia, muscle or bone)

o  Type of CLOSURE for each lesion (e.g., simple, intermediate or complex)

Please document and/or addend the patients’ operative/procedure record to include the requested information above.  This information can be noted in the electronic medical record, or noted on this form as noted by you in the area below.  If you are using this form, please sign and date the attestation/addendum.

The relationship between the documentation and the coding is a very intricate and oftentimes confusing process.  Every chart note, or clinical documentation the record must stand on its own merit.  If the record is audited, the coding should accurately reflect what was noted by the provider.   As a coder, the documentation should always clearly reflect this set of criteria listed below:

·         Clinical Evaluation and work-up to include any pertinent history
·         Diagnostic and/or Therapeutic Treatment(s) carried out or ordered (such as lab tests, x-rays etc.)
·         Continued plan of care or follow up plans
·         Clinical diagnosis of disease, signs and/or symptoms.
·         Documentation of patient education provided in regard to the above

The usage of an electronic medical record for outpatient care and office based services has also been instrumental in giving the coder a clearer picture of the overall care and services provided to the patient.  Many electronic medical records allow the physician to choose the ICD-10cm diagnosis code and include the additional supplies or procedures performed during the visit.  If the provider documents the diagnosis for any performed procedures via an electronic record, the coder now has the additional role of auditing the patient record and the actual diagnosis codes chosen by the provider prior to billing the 3rd party insurance payers. 

If upon review by the coder, that the physician or provider has not chosen the “most specific” of codes, the coder/auditor now has the unique opportunity to easily review, clarify and/or correct any errors quickly and easily prior to a claim being sent out.   In addition, some payers have the capability to accept electronic copies of the patients’ clinical documentation for their review or pre-authorization to expedite payment of services rendered.   

Outpatient and office based services are not always about illness.  Wellness services, preventive care, pre and post operative care, and specialty specific diagnosis care are all a part of outpatient and office based services.  ICD-10cm has accounted for these types of encounters.  If these encounters are well documented, they also need to be coded, billed and incorporated into the claim.  Many 3rd party payers are now providing coverage for payment of screening services.

The ICD-10cm coding guidelines give clear instruction for how these type of services are to be reported.  Again, it is the physicians role to clearly state within the clinical documentation that the patient has presented for a wellness exam, or has presented for screening testing for specific illnesses or diagnoses (such as a pap test for cervical cancer, a colonoscopy to screen for colon cancer, lab tests for elevated blood sugar/diabetes) .  In these cases the coding should reflect a clear diagnosis of screening.  The screening diagnosis may be the only diagnosis assigned, as it may truly be the only “reason” for the patient visit.  

It is becoming more common that the physician will be following and providing care for both an established chronic problem, and also “screen” for other issues during the same encounter.  If this is the case, the coder needs to audit and review the notes carefully to ensure that the record clearly denotes what has been performed in regard to “follow up” and what has been performed as “screening” (for either wellness, or a suspected illness)   If the record does not clearly show these as separately identifiable services, a physician query and/or addendum is in order.

Last but not least, always “code what the record shows”.  If you are in doubt, query.  Many coders rely on the old adage of “if it wasn’t documented, it wasn’t done”.   This type of coding should no longer be the rule of thumb or status quo.  As a good coder, if it appears in the clinical documentation,  a service or procedure was performed,(but poorly documented) it is well worth the time to investigate, confirm, have the record amended, then coded with accuracy.   

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at or you can also find current coding information on her blog site:   

No comments:

Post a Comment