Ophthalmology and Optometry Coding Alert

Question: I have a doctor that wants to see in writing where she has to document anywhere in her note, other than the diagnosis code she chose, the specificity of a condition. The issue in argument is for cataracts. She feels as long as her HPI indicates patient has cataracts and she picks a specific diagnosis code, that is enough. She said we are making this up, or it has been passed on like an old wives' tale. Now she is making me doubt myself. She wants it in writing. Nothing that I say or that anyone can say will sway her. What should I do?

Codify Subscriber

Answer: The ICD-10 guidelines address specificity, and although you can lead the doctor and show her the regulations in black and white, you may not be able to make her comply.

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."