Gastroenterology Coding Alert

Question: One of our gastroenterologists wants to see in writing where she has to document anywhere in her note, other than the diagnosis code she chose, the details of the specific condition. What should I do?

Codify Subscriber

Answer: The ICD-10-CM guidelines address specificity. Per the introduction: “A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized.

Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

Per section I.A.9.b of the 2019 ICD-10-CM Official Guidelines for Coding and Reporting, “Codes titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code.” Additionally, per section I.B.18, “Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation…”

Strategy:  So, if the physician doesn’t comply and the notes don’t support the diagnosis code, you should report the unspecified code option. Keep track of denials to show the provider at a later time if there is a consequence for not reporting the most specific code supporting the service(s) rendered.