Wiki Missing documentation for external cause injury codes

[jnieto625]

Patient comes in for a hospital f/u diagnosed with a concussion. There is no documentation in the visit note as to how it happened but it is very clear in the hospital notes. I have always been taught that a note must stand alone for coding so I queried my provider and asked her to please review as external causes were not documented. She does not feel she has to document this. Does anyone have any documentation they can share regarding this or am I incorrect to query my physicians when this happens?

 

[thomas7331]

Per the ICD-10 official guidelines, external cause codes are not required - unless your state or payer mandates them, reporting is voluntary. In my previous practice, I would not query the provider or otherwise go looking for this information if it was missing from the documentation. I never encountered any issues with denials or rejects for not having these codes on the claim. Usually if the payer needs specific information about an accident, they'll request it in writing rather than require it in the coding.