# Documentation Guidelines regarding diagnosis.



## lillianivy (Aug 12, 2015)

Our new EMR now populates the ICD-9/ICD-10 codes to the actual record(That the physician chooses).  So the physicians say they will no longer need to document the diagnosis under the plan/assessment.  This makes me nervous.  Is that sufficient documentation? Plus with ICD-10 and them not knowing all the guidelines I am nervous of them selecting the wrong one.  And if they don't document in addition to the selection how am I to know if it is correct or incorrect.  

For an auditor reviewing this record, is this ok?  They wouldn't need to physically document the diagnosis in addition to the code?

Thank you,
Lydia


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## mitchellde (Aug 12, 2015)

The provider is not allowed to use the code as a substitute for the dx rendered in their own words.  See coding clinic 1st quarter 2012.


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## lillianivy (Aug 13, 2015)

mitchellde said:


> The provider is not allowed to use the code as a substitute for the dx rendered in their own words.  See coding clinic 1st quarter 2012.



Do you have a link to that?  I have been trying to find it but have been unsuccessful. 

Thank you,
Lydia


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## mitchellde (Aug 13, 2015)

lillianivy said:


> Do you have a link to that?  I have been trying to find it but have been unsuccessful.
> 
> Thank you,
> Lydia



There is no link. This is a publication that must be purchased.  The information is copy protected and cannot be verbatim shared.  It is excellent and well worth th price.it also recognized by all authorities as the compliant resource. You ca order back issues. Yo will need to got to the AHA store.


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## lillianivy (Aug 13, 2015)

Just to be clear, the ICD-9/ICD-10 description is attached along with the code. 

Example:
174.9 - Breast Cancer, unspecified - Primary
198.5 - Bone Mets - Primary
787.01 - Nausea and Vomiting - Secondary

It is positioned at the top of the Office Note.


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## mitchellde (Aug 13, 2015)

But that is the code descriptor which is not the same as the provider rendering the diagnosis in his words.


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## lillianivy (Aug 13, 2015)

mitchellde said:


> But that is the code descriptor which is not the same as the provider rendering the diagnosis in his words.



Thank you.  Just needed that to be clarified.  I thought so, as well, but it helps to have another coder and/or auditor's feedback to support me.


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