# Provider documenting ICD-10 codes in lieu of text definition



## bridgettemartin (Aug 17, 2018)

I have a NeuroPsych Provider that documents the actual ICD-10 code on testing reports in lieu of a text definition.  I think I read something from CMS a few years back about this, and I believe it said that the actual text definition must be in the note.  However, I have been searching for this guidance and cannot find anything.  Do any of you have an official guidance on this?

Much appreciated!!


----------



## thomas7331 (Aug 17, 2018)

You can find this in your ICD-10 code book, in the Official Guidelines for Coding and Reporting, Section I A (Conventions for the ICD-10-CM) under Code assignment and Clinical Criteria, where it states:  "_The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists_."  Obviously, if there is no diagnostic statement, then there can be no ICD-10 code choice on which to base it or validate it.  

Explain to your provider that an ICD-10 code is not a diagnosis, it is a classification, just as a Dewey decimal number is a classification for a group of topics of books in a library.  Some ICD-10 codes may represent multiple different actual diagnoses.  It is not clinically appropriate to use a code in place of a diagnosis, because it is not a diagnosis.


----------



## bridgettemartin (Aug 17, 2018)

thomas7331 said:


> You can find this in your ICD-10 code book, in the Official Guidelines for Coding and Reporting, Section I A (Conventions for the ICD-10-CM) under Code assignment and Clinical Criteria, where it states:  "_The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists_."  Obviously, if there is no diagnostic statement, then there can be no ICD-10 code choice on which to base it or validate it.
> 
> Explain to your provider that an ICD-10 code is not a diagnosis, it is a classification, just as a Dewey decimal number is a classification for a group of topics of books in a library.  Some ICD-10 codes may represent multiple different actual diagnoses.  It is not clinically appropriate to use a code in place of a diagnosis, because it is not a diagnosis.




Very good way to word that.  I knew about the guideline in the ICD-10 book, but I guess I couldn't see the forest for the trees there.  I kept looking for something that said 'you can't do this'.  
Thanks!


----------



## Cynthia Hughes (Aug 20, 2018)

*Diagnosis documentation*



bridgettemartin said:


> Very good way to word that.  I knew about the guideline in the ICD-10 book, but I guess I couldn't see the forest for the trees there.  I kept looking for something that said 'you can't do this'.
> Thanks!



Here is what I usually reference: Coding Clinic, First Quarter 2012, "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. Therefore, it is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement."


Though this addressed ICD-9-CM, it is valid still.

Hope that helps,
Cindy


----------



## bridgettemartin (Aug 21, 2018)

Cynthia Hughes said:


> Here is what I usually reference: Coding Clinic, First Quarter 2012, "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. Therefore, it is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement."
> 
> 
> Though this addressed ICD-9-CM, it is valid still.
> ...



yes.  thanks!!


----------

