Wiki ICD-9 codes should not appear in the chart notes or other medical records?

[dparker19]

Is it true that as of October 1st, 2012- all diagnosis codes need to be removed from all documentation including office visits, chart notes, etc.

I have searched several websites including CMS and I do not find any documentation of this. Apparently someone attended a seminar where that information was given but no mention of who and where it is coming from. Thanks!

 

[Walker22]

I have not heard this, and it would be nearly impossible to implement anyway. I am highly doubtful of its authenticity. If anyone has information to the contrary, please share!

 

[mitchellde]

There is no such regulation that i am aware or. However ICD-9 codes do notneed to beinthe medical record, I think some believe thatthis the wayit has to be but this is not true. I personally th8nk it is better if the code itself is not in the chart note. What must be there is the narrative diagnosis.

 

[dparker19]

Thanks for your quick response. I just rec'd an email stating this person heard this at her local AAPC chapter meeting in Pontiac MI and she notes the source as PK Services and the Coding Clinic 1st Quarter 2012. I will see if I can locate these sources and post an update if I find anything. If any of you are aware of these sources and how to contact them, please let me know. Thanks Again!

 

[mitchellde]

coding clinics are a pay for service thru the AHA and are considered the final word in coding instruction. They are well respected by all other coding authorities. You can obtain this issue thru the AHA but you will need to pay for it. OR if you know someone in a facility med records department they probably subscribe to these and may allow you to read this issue. If you post anything from a coding clinic be sure you do not cut and paste the exact verbage as these are a copy protected source. You can however summarize the information for this forum if you obtain it. I am equally intrigued by this , and would be interested in any addition info you get.

 

[mhstrauss]

I was able to read the Coding Clinic referenced above, and I'm not sure I understand it to mean "ICD9's cannot be listed in the EMR documentation". My interpretation of the article is that the ICD9 cannot be in lieu of the narrative code description...the ICD9 can be there, but the narrative and supporting documentation must be there also. I personally am in agreement with Debra, that it should not be, because then the docs get too caught up in looking at numbers instead of documenting thoroughly, but that's just my opinion...