Medicare Claims Processing Manual Chapter 23 -Fee Schedule Administration and Coding
I am attempting to find something in writing from Medicare in regards to diagnosis coding off the documentation.
Example. A provider's record does not document the sign/symptom nor diagnosis(s) of the patient. Only what was performed. It has been my understanding that on an audit perspective, you cannot code that charge because there is no diagnosis to that particular record.
The coder is pulling a diagnosis from the EMR to code that case. I believe this is not allowed by CMS, but I am having a rough time trying to find that in writing.
I read the False Claims Act, but really nothing in writing I can find that says just what I mentioned. I have to present that information to the provider.
Any help would be most appreciated!!
Complying With Medical Record Documentation Requirements
Insufficient Documentation Errors
Claims are determined to have insufficient documentation errors when the medical documentation submitted is inadequate to support payment for the services billed (that is, the reviewer could not conclude that some of the allowed services were actually provided, were provided at the level billed, and/or were medically necessary). Claims are
also placed into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety.
Insufficient documentation errors identifiedby the CERT RC may include:
Incomplete progress notes (for example, unsigned, undated, insufficient detail);
Unauthenticated medical records (for example, no provider signature, no supervising signature, illegible signatures
without a signature log or attestation to identify the signer, an electronic signature without the electronic record protocol or policy that documents the process for electronic signatures); and
No documentation of intent to order services and procedures (for example, incomplete or missing signed order or progress note describing intent for services to be provided).
https://www.cms.gov/Outreach-and-Ed...wnloads/CERTMedRecDoc-FactSheet-ICN909160.pdf
Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements
10.3 - Outpatient Claim Diagnosis Reporting
(Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10,
Implementation: Upon Implementation of ICD-10)
For outpatient claims, providers report the full diagnosis code for the diagnosis shown to be
chiefly responsible for the outpatient services. For instance, if a patient is seen on an
outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive
diagnosis is not made, the symptom is reported. If, during the course of the outpatient
evaluation and treatment, a definitive diagnosis is made (e.g., acute bronchitis), the
definitive diagnosis is reported. If the patient arrives at the hospital for examination or
testing without a referring diagnosis and cannot provide a complaint, symptom, or
diagnosis, the hospital reports the encounter code that most accurately reflects the reason
for the encounter.
10.5 - Coding for Outpatient Services and Physician Offices
(Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10,
Implementation: Upon Implementation of ICD-10)
The Official ICD-10-CM Coding Guidelines include a section for Outpatient Services
(hospital-based and physician office). These guidelines can be found in the annual updates
to ICD-10-CM posted at
http://www.cms.gov/Medicare/Coding/ICD10/index.html
Contractors, physicians, hospitals, and other health care providers must comply with the
Official ICD-10-CM Coding Guidelines.
10.6 - Relationship of Diagnosis Codes and Date of Service
(Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10,
Implementation: Upon Implementation of ICD-10)
Diagnosis codes must be reported based on the date of service (including, when applicable,
the date of discharge) on the claim and not the date the claim is prepared or received.
Medicare contractors are required to edit claims on this basis, including providing for
annual updates each October.
Shared systems must maintain date parameters for diagnosis editing. Use of actual
effective and end dates is required when new diagnosis codes are issued or current codes
become obsolete with the annual updates.
The Health Insurance Portability and Accountability Act (HIPAA) requires that medical
code sets must be date-of-service compliant.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf
