Wiki ICD-9 pick list

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skrautkramer

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Where I work we are currently using a program that allows the attending to select an ICD-9 code with attached text. This appears in the final note; however this is the only place the diagnosis is recorded. Can this be used as the diagnosis for the claim or should the attending still document the patient's diagnosis somewhere in the body of their note? I have looked high and low on any rules that apply to this, but all I can find is an article in the February 2010 Coding Edge (pg 29) that makes me think that this cannot be used.
 
The diagnosis must be stated in the note not just a code. Our codes themn come from the diagnosis and may or may not match the selected code.
 
Yes, I understand that they cannot just have an ICD-9 code only. The problem is that the code has attached text.
Ex:
Chest pain (786.50)
 
The thing is that there are way more dx's than there are codes.
Someone can have chest pain, or a more specific dx or rib pain which would both fall into 786.50.
Just seems that should somone need their records sent out for a consult etc. They would want an actual dx attached to it not just an icd-9 code.
 
Yes, yet again I understand that if it only had 786.50 in the note it would not be appropriate to use because the documentation does not state chest pain. What I would like to know if it is appropriate to use if it has attached text that does appear in the documentation like the example that I have given above? Does anyone know of any guidelines on this? Is it appropriate to use this when there is attached text to the ICD-9 code selection?
 
In my facility we use electronic coding coded by Physicians. Still it is not 100% correct. (Ex: HTN 401.1 but document does not say Benign HTN. Code should be 401.9.) As per the physician they donot see a big difference with that 1 word BENIGN . It is OK for them to code 401.1.I have many many more example like Asthma,Rash,Dermatitis etc.,
 
Our EMR came with a pick list which the business office has successfully petitioned to be disabled so that only the words show in the documentation. The pick system was for one - not very user friendly; and two - was extremely inaccurate. If you are going to use the code from the EMR make absolutely certain it is pulling in what the physician truly wants to report. Otherwise, I highly recommend NOT using EMR for ICD-9 coding.
 
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