# Documentation requirements



## Mraquelcook3@gmail.com  (Feb 2, 2021)

Can anyone direct me to where I can find information other than maybe office policy that provider needs to attach DX codes to procedures/ E/M visits when he is writing out the DX  and medical necessity within his documentation.
Thanks in advance


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## csperoni (Feb 2, 2021)

I don't think you will find such a document as the provider is NOT required to attach dx codes, other than perhaps office policy.  The provider needs to indicate the diagnosis, but not the codes.  Many EHR systems will attach codes when the physician selects a written diagnosis, but a coder (or anyone depending on employer policy) may correct the code.  
Real life example: provider documents a diagnosis of high risk HPV from cervical PAP.  However, when provider types "HPV" in EHR, B97.7 comes up, which is "Papillomavirus as the cause of diseases classified elsewhere."  Without query to provider, we may correct B97.7 to R87.810.  We are correcting the code, but not changing the diagnosis.    
Some employers may require their physicians to assign codes, but I am certainly not a fan of such a policy.


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## MC1260 (Mar 8, 2022)

@ csperoni does this apply to ED coding as well, I really struggle with this. I see so many incorrect Dx codes and my Manager tells us to code as is and I done agree with that


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## csperoni (Mar 8, 2022)

MC1260 said:


> @ csperoni does this apply to ED coding as well, I really struggle with this. I see so many incorrect Dx codes and my Manager tells us to code as is and I done agree with that



Yes, this would apply to ED POS.  The provider is required to provide the diagnosis, not the diagnosis CODE.  A coder (or anyone your employer permits) may change the code if the physician assigned the wrong code.  
If the physician wrote "DM II no complications well controlled" and put the code E10.641 which is DM I with hypoglycemia with coma, you certainly should correct that to E11.9.  To me, that's exactly the job description of a medical coder.  It's to take the clinician's words and assign CPT, ICD10, modifiers, etc.  
What a coder may not do is take the words "elevated blood sugar" and assign DM II if the physician did not diagnose diabetes.  
Some employers may have policies for only clinicians to correct the code.  In my opinion, those policies may be well-intentioned, but wind up with either the claims being submitted with known incorrect diagnoses, or clinicians needing to waste time on administrative documentation instead of focusing on patient care.
You are not coding correctly if you submit codes you know are incorrect.  What is the point of having a coder if the claims are going with whatever the clinician assigned?


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## Sarah Ann (Mar 9, 2022)

AHA CC-1st quarter 2012- narrative diagnosis in the documentation- as opposed to an alpha-numeric code picked from a drop down or pick list.


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