Appropriate coding of medical claims serves several purposes. It provides clues to the complexity of a patient’s condition, the level of care required, as well as the projected costs and care management resources involved in delivering optimal care to that patient. Accurate ICD-10 diagnosis coding to the correct level of specificity is challenging, however, and requires that clinicians apply the extent of their clinical knowledge to document the full range of conditions and comorbidities impacting a patient’s health.
Essentially, if a condition is not appropriately documented in a patient’s medical record, for all intents and purposes, it is deemed to be nonexistent. It’s important to keep in mind, then, that each progress note in the medical record must:
Additional tips for ensuring proper documentation and diagnostic coding are detailed in the chart below.
|Code and report a condition as many times as the patient receives care and treatment for that condition.
|Do not carry over a diagnosis from visit to visit or year to year.
|Code a condition when documentation indicates the condition is being monitored, assessed, and/or treated by a specialist. (Example: “Patient on Coumadin for atrial fibrillation; followed by Dr. Jones.”)
|Do not code for conditions that were previously treated and no longer exist.
|Code for coexisting conditions when documentation indicates that the condition affects the care, treatment, or management of the patient.
|Do not code unconfirmed diagnoses. Until a diagnosis is confirmed, only signs and symptoms should be coded.
|Document and code status conditions (e.g., amputations or ostomies) at least once a year.
|Do not use arrows or symbols alone to indicate a diagnosis.
Cynthia Farrelly, RN, BSN, Accreditation and Quality Program Manager, CDPHP Quality Enhancement Department
Should you have questions related to diagnostic coding, please contact the CDPHP Risk Adjustment team at RiskCoding@cdphp.com.