Primary Care Coding Alert

Question: Our providers sometimes enter ICD-10 codes into a patient’s electronic medical record (EMR) incorrectly. As an example, some codes in our EMR default to bilateral, but the correct code choice should specify right or left per the provider’s progress note. Also, some providers copy an unspecified diagnosis from a previous visit even when the subsequent visit shows that the diagnosis has changed to something more specific. In cases like this, when the note clearly supports a correction to the diagnosis code in the claim/billing module, our office policy is to make the change without notifying the provider. Is this policy correct, or should we change it to notify the provider every time we make the change?

Utah Subscriber

Answer: ICD-10 guideline 1.A.19. states that “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient.”

In other words, ICD-10 is saying that you should assign codes from the provider’s notes, not based on a code chosen by a provider. So, providing the note supports the code choice, there is no reason why you cannot go ahead and enter the correct code. There are no guidelines stating that you have to notify the provider that you have done so, though you should clearly follow established office protocols, ethical guidelines, and common courtesy before changing any code.

However, if the note is vague, and you cannot choose a specific code based on what the provider has written, then you must go back to the provider and ask her to clarify the diagnosis in the note.

Finally, the situation you describe suggests that both you and your provider should collaborate on changing the way diagnoses are entered into the patient’s EMR. Use this as an opportunity to educate your provider about how the codes are being entered in error, and perhaps even disable the code feature in the EMR.