# Thought this was an easy question...



## MnTwins29 (Nov 16, 2011)

I was asked by our legal department where it is stated that the documentaion for a diagnosis that is coded must be documeneted by a physician or legally responsible provider.   Sounded easy - first page of the Official Coding Guidelines, right?   Well, because it doesn't explicitly say "physician", I am being asked to find another source....and that is proving tough.    Any other ideas?


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## nrichard (Nov 16, 2011)

*I can only give you a place to tell THEM to start looking.*

Your not the lawyer and you shouldn't have to be.
   If you look at the first page in ICD-9 under Official ICD-9-CM Guidelines for Coding and Reporting, states that "adherence to these guidelines when assigning ICD-9-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPPA). I believe that if they go through the entire document they will find the information they are looking for. Considering the length and the technical jargon, I personally would not even attempt to research it beyond that, due to the fact law is "outside of my scope of practice". 
 I only word it this way, because that is how I would present it to them. Of course if anyone has something better, by all means please speak up, (I'd love to have a better answer)


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## dclark7 (Nov 16, 2011)

Print out the CMS E & M Services Guide.  The top of page four (also found in most insurance companies Medical Records Standards) states "The documentation of each patient encounter should include: 1) The reason for the encounter and relevant history, physical examination finding and prior diagnostic test results; 2) Assessment, clinical impressions or diagnosis; 3) Medical plan of care and; 4) Date and legible identity of the observer."
Further down on the page there is a paragragh which states" When billing for a patient's visit, select codes that best represent the services furnishedj during the visit.  A billing specialist of alternate source may review the provider's documented services before the claim is submitted to a payer.  These reviews may assit with selecting codes that best reflect the provider's furnished services.  However, it is the provider's responsibility to ensure that the submitte claim accurately relcts the services provided."
The Guide goes on the say on page 5 that the two common sets of codes that are currently used for billing are: CPT and ICD.
Page 6 also lists the providers who can furnish E/M services.  Since the encounter must be documented by the person who provided the service, this may give them the answer they are looking for.


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## btadlock1 (Nov 16, 2011)

MnTwins29 said:


> I was asked by our legal department where it is stated that the documentaion for a diagnosis that is coded must be documeneted by a physician or legally responsible provider.   Sounded easy - first page of the Official Coding Guidelines, right?   Well, because it doesn't explicitly say "physician", I am being asked to find another source....and that is proving tough.    Any other ideas?



E/M Documentation guidelines sort of say it (Under MDM):
"The number of possible diagnoses and/or the number of management options that must
be considered is based on the number and types of problems addressed during the
encounter,* the complexity of establishing a diagnosis and the management decisions
that are made by the physician*.

Generally, decision making with respect to a diagnosed problem is easier than that for
an identified but undiagnosed problem. The number and type of diagnostic tests
employed may be an indicator of the number of possible diagnoses. Problems which
are improving or resolving are less complex than those which are worsening or failing to
change as expected. The need to seek advice from others is another indicator of
complexity of diagnostic or management problems.

DG: For each encounter, an assessment, clinical impression, or diagnosis should
be documented. It may be explicitly stated or implied in documented decisions
regarding management plans and/or further evaluation.

For a presenting problem with an established diagnosis the record should
reflect whether the problem is: a) improved, well controlled, resolving or
resolved; or, b) inadequately controlled, worsening, or failing to change as
expected.

For a presenting problem without an established diagnosis, the assessment
or clinical impression may be stated in the form of a differential diagnoses or
as "possible,” "probable,” or "rule out” (R/O) diagnoses."

The 'general principles' say that the diagnosis should be clearly indicated, along with the legible identity of the observer, but it doesn't say that it _MUST_ be a physician. I also think that it probably falls somewhere under 'scope of practice' criteria, but I'm not sure...


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## nrichard (Nov 16, 2011)

MnTwins29 said:


> I was asked by our legal department where it is stated that the documentaion for a diagnosis that is coded must be documeneted by a physician or legally responsible provider.   Sounded easy - first page of the Official Coding Guidelines, right?   Well, because it doesn't explicitly say "physician", I am being asked to find another source....and that is proving tough.    Any other ideas?



I thought you were asking about something more along legal guidelines to present to them.


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## btadlock1 (Nov 16, 2011)

This may be helpful - http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_028509.hcsp?dDocName=bok1_028509


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## MnTwins29 (Nov 17, 2011)

*Thanks!*



nrichard said:


> I thought you were asking about something more along legal guidelines to present to them.



Yes, that is the direction I was going with it - espcially when the follow-up question came when the Official Guidelines were not clear enough for the person who asked me.   However, I am going to gather all of your suggestions and present them.   I didn't think of the E/M guidelines since this issue didn't involve E/M coding, but when I re-read them after reading these responses, I think that will certainly help.

Thanks to all who responded.   

Lance


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## jonvieve (Nov 23, 2011)

MnTwins29 said:


> I was asked by our legal department where it is stated that the documentaion for a diagnosis that is coded must be documeneted by a physician or legally responsible provider.   Sounded easy - first page of the Official Coding Guidelines, right?   Well, because it doesn't explicitly say "physician", I am being asked to find another source....and that is proving tough.    Any other ideas?



The introduction to ICD-9-CM Offical Guidelines for Coding and Reporting states "The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean _physician or any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis_." This statement is in the fourth paragraph.

The ICD-9 Guidelines are mandated by HIPAA and must be adheared to whenever transmitting healthcare data from one party to another party for payment. This is stated in HIPAA, not in the guidelines. 

The party responsible for issuing payment for services dictates who is a "quilified health care practitioner" and this differs by payor. Such as one payor will remit payment for a service provided by a nurse practioner, where another will not remit payment unless the documentation is signed by a physician. Some payors will remit payment to a Licenced Social Worker, a Massage Therapist, a Chiropractor, while others will only remit to an MD.


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