March 19, 2007

Coding From Diagnostic Studies
For The Record
Vol. 19 No. 6 P. 33

In the inpatient setting, coders are not allowed to assign codes from diagnoses listed on diagnostic reports such as radiology, pathology, and echocardiogram (ECHO) even if a physician has signed the diagnostic report. The diagnosis must be confirmed by the physician in the body of the medical record (eg, progress notes or discharge summary) before it can be coded.

However, if the diagnostic report is adding specificity to an already confirmed diagnosis, then the coder may use the more specific code based on the diagnostic report without obtaining physician confirmation (AHA Coding Clinic for ICD-9-CM, 1999, first quarter, page 5).

Occasionally, the physician may document diagnostic findings in the progress notes such as “ECHO showed mitral regurgitation (MR)” or “chest x-ray (CXR) showed pleural effusion.” Coders often wonder whether it is appropriate to assign a diagnosis code based on this physician documentation. The answer depends on the following specific patient circumstances:

• diagnostic study performed;

• other related conditions documented in the medical record; and

• findings which may be inconsistent with the patient’s history.

Every record has to stand on its own merits. Before a condition can be coded, it must meet two requirements. One, it has to be documented by a physician in the body of the medical record such as the history and physical, consult report, progress notes, or discharge summary. The second requirement is that it must affect patient care in terms of requiring one of the following five criteria:

• clinical evaluation;

• therapeutic treatment;

• diagnostic procedure;

• extended length of hospital stay; and

• increased nursing care and/or monitoring.

In the first example listed above of “ECHO showed MR,” it may be appropriate to assign a code for the MR as a secondary diagnosis. An ECHO is not a routine diagnostic study performed on every patient. Maybe the ECHO was performed to evaluate the MR that was previously diagnosed. Therefore, it may be appropriate to assign a code for the MR because the physician documented the condition in the body of the medical record (rather than just on the diagnostic report) and the condition was evaluated.

However, in the second example listed above of “CXR showed pleural effusion,” a CXR is a more common diagnostic study and pleural effusion may be inherent with other conditions that the patient may have (ie, congestive heart failure). Questions the coders should ask themselves are: Why did the physician order the CXR? Was it to evaluate the pleural effusion? If not, what else did they do to evaluate, monitor, or treat for the pleural effusion? If the pleural effusion was an incidental finding on the CXR, then it should not be coded if it was not evaluated, monitored, or treated even if the physician documented it in the progress notes or discharge summary.

Another example could be “CXR showed chronic obstructive pulmonary disease [COPD]” documented in the progress notes by a physician. COPD is a condition that can be coded as a secondary diagnosis in the absence of active intervention because it is a chronic systemic condition (AHA Coding Clinic for ICD-9-CM, 1992, second quarter, pages 16-17).

However, assigning a code for COPD may be concerning if the patient does not have a past medical history of COPD or current clinical signs and symptoms of COPD and no history of smoking. If the coder questions the validity of a diagnosis, then the coder needs to query the physician for clarification prior to code assignment. The physician may have documented it as “CXR showed COPD,” but if the rest of the record does not support the diagnosis, the coder needs to query for clarification.

In summary, it is acceptable to assign a code from a condition the physician has documented in the progress notes based on a diagnostic study, such as “ECHO shows MR,” if the condition meets the reportable diagnosis criteria.

Coding From Nonphysician Provider Documentation
Many nonphysician specialists (such as nurse practitioners, physician assistants, physical therapists, respiratory therapists, and nutritionists) document diagnoses in the medical record. According to AHA Coding Clinic for ICD-9-CM, “the facility should report diagnoses on the basis of the provider who is legally accountable for establishing a diagnosis within the regulations governing the provider and the facility” (2006, third quarter, page 10).

The Editorial Advisory Board for AHA Coding Clinic for ICD-9-CM believes that deciding who is legally accountable for establishing a diagnosis is beyond their scope of authority. Each hospital has to decide whether it is going to assign codes based on a nonphysician provider’s documentation. A question to consider is: Do the state’s licensing laws allow nonphysician providers to establish a diagnosis? Please note that not all state laws are the same. The decision to assign codes based on nonphysician provider documentation should be discussed and approved by each individual facility.

Coding and sequencing from diagnostic studies are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

—Audrey Howard, RHIA, of 3M Consulting Services, prepared this information. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or 800-367-2447.