Question: Our practice is submitting claims for lab orders and they keep getting denied. Our new practice manager suggested that the coding team can go into the system and adjust the diagnosis code related to the lab order, to make sure that the lab order is associated with a diagnosis code that will be paid. The coding team doesn’t feel great about this, but we also don’t have anything in writing saying that coders changing diagnosis codes is not a compliant solution. Should we resist this advice? AAPC Forum Participant Answer: Most coders know that they cannot make medical judgements, and changing the diagnosis code associated with a lab order — and therefore adjusting the documented reason for the lab order — might be considered a clinical call. For example, if a patient has a thyroid issue and hypertension, and the physician orders blood work to check on some values pertaining to hypertension, but the coder adjusts the order so the accompanying diagnosis is related to the thyroid problem, then the documentation no longer reflects the provider’s clinical judgement in ordering the bloodwork. Additionally, a coder adjusting a provider’s documentation, including regarding a diagnosis, may raise compliance issues that could create big headaches down the line. However, there may be situations in which a coder works with a physician to adjust a diagnosis or procedure code. The AMA says that physicians and other qualified healthcare professionals are ultimately responsible for using the correct diagnosis and CPT® codes, but other “appropriate individuals” may “physically enter or change the code when authorized.” The AMA notes that there are no federal regulations nor CPT® guidance saying that only physicians or healthcare billers can enter or change diagnosis or procedure codes, nor are there any federal regulations or CPT® guidance prohibiting certified professional coders (CPCs) from reviewing diagnosis and procedure codes for compliance. It’s also important to note that the ICD-10-CM guidelines say that achieving complete and accurate documentation, coding, and reporting of diagnoses should be a joint effort between physicians and coders. Ultimately, coders and clinicians should work together to ensure that coding is complete and accurate — and coders should not make any changes that have not been expressly authorized by the respective clinician. Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC