By Melody W. Mulaik, MSHS, CRA, FAHRA, RCC, CPC, CPC-H
In an effort to streamline the conversion to ICD-10, some hospitals have begun requiring referring physicians to provide ICD-10-CM diagnosis codes on their orders for imaging services, either in lieu of or in addition to the clinical indications for the study. However, substituting a diagnosis code number for a narrative statement of clinical indications may have a negative impact on patient care and is contrary to official ICD-10-CM coding guidelines.
The ACR Practice Parameter for Communication of Diagnostic Imaging Findings (2014) states:
A request for imaging should include relevant clinical information, a working diagnosis, and/or pertinent clinical signs and symptoms. In addition, including a specific question to be answered can be helpful. Such information helps tailor the most appropriate imaging study to the clinical scenario and enhances the clinical relevance of the report, thus promoting optimal patient care.
A diagnosis code does not provide the information that the radiologist and imaging facility require in order to ensure that the study fully addresses the clinical question. For example, carotid bruit is classified to ICD-10-CM code R09.89 (Other specified symptoms and signs involving the circulatory and respiratory systems), together with conditions like abnormal chest percussion, choking sensation, rales, and weak pulse. If provided by itself, this code tells the imaging facility and radiologist virtually nothing about the patient’s problem.
Moreover, official diagnosis coding guidance (AHA Coding Clinic®, First Quarter 2014) states that “it is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement.” Coding Clinic® goes on to point out that some diagnosis codes include multiple different conditions, and it may be clinically important to distinguish among those conditions. Additionally, some conditions require more than one diagnosis code to describe. The article states that for this reason, “it is the provider’s responsibility to provide clear and legible documentation of a diagnosis, which is then translated to a code for external reporting purposes.”
In summary, hospitals are strongly encouraged not to substitute a diagnosis code for appropriate clinical history.
Melody W. Mulaik, MSHS, CRA, FAHRA, RCC, CPC, CPC-H is the president of Coding Strategies, Inc. in Powder Springs, GA. She is a member of AHRA’s regulatory affairs committee. She can be reached at Melody.Mulaik@codingstrategies.com.