Pediatric Coding Alert

Question: If a patient tells the medical assistant (MA) who rooms the patient that they are experiencing pruritis, but the provider does not include pruritis in his/her note, can we as coders denote L29.8 as one of the diagnosis codes linked to the anatomical region the patient reports itching? I run into this situation often.

Illinois Subscriber

Answer: You can use what patient says, but only if their words are documented by someone qualified to make a diagnosis. MAs are not considered qualified healthcare professionals (QHPs), and therefore anything they document should not be coded without first checking with the provider.

First, it’s important to remember who is allowed to document in the patient’s record and what they can, and cannot, report. ICD-10 Guideline I.B.14 tells you “Code assignment is based on the documentation by the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing a patient’s diagnosis.)”

The guideline goes on to mention a few exceptions to this rule:

• Body mass index (BMI)
• Depth of non-pressure chronic ulcers
• Pressure ulcer stage
• Coma scale
• NIH stroke scale (NIHSS)
• Social determinants of health (SDoH)
• Laterality
• Blood alcohol level

So, the guideline explains that a dietitian might document BMI, and an emergency medical technician (EMT) might document the coma scale.

Additionally, guideline I.C.21.c.17 explains that “Patient self-reported documentation may be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the medical record by either a clinician or provider.”

In your scenario, even though MAs are qualified to provide a lot of the basic care — such as performing phlebotomies, taking vital signs, dressing wounds, updating records, and even educating patients on a variety of health issues — they cannot document many of the above. Most important, however, they cannot document any clinical diagnoses such as any L29.8 (Other pruritus). Only a physician or QHP can document such a diagnosis.