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Codes alone don't provide clarity in notes


In this installment, you'll learn whether writing just the code without an explanation in the assessment/plan section is adequate. Find out the answer to this pressing coding question.

Q: I have an odd question. I have a memory for numbers. Thus, I have committed to memory several ICD-9 codes (for example, 401.1 is the number I use most frequently for hypertension). Somehow I developed a habit of writing, in the note's assessment/plan section, the number without the narrative. Is the number adequate? The code is complete, easy-to-read, well understood, and, I believe, concise.

Just as important, coding allows you to create accurate medical records that convey good information about patients and the care they receive. Correct diagnosis coding is critical for denoting the medical necessity for services provided and ensuring proper adherence.

■ S represents the Subjective portion of the note, which includes the chief complaint and generally the history of the present illness, as well as a medical, family, and social history. It coincides with the documentation for evaluation/management services.

■ O is for the Objective part of the note, or the results of an examination that may include height, weight, and blood pressure, as well as a physical.

■ A represents the Assessment portion of the note and the medical decision-making that indicates the disease or problem.

■ P is for Plan and shows in the note what should be done to treat the disease or problem.

Your question states that, instead of actually putting into words the disease process(es), you merely state the ICD-9 code.

The ICD-9 coding system is the nomenclature system used to describe "why we do the work" or the underlying diagnosis for the work physicians do. It is a three-, four-, or five-digit numbering system that relates to each recognized diagnosis, injury, symptom, and illness.

Although you say you have a good memory for numbers, these codes change yearly. It is difficult enough for the front-office staff to keep up with the changes, let alone the physicians. Fortunately, many electronic health record systems bring up the ICD code if the assessment contains the name of the disease.

Practices will experience a major problem when ICD-10 is implemented, because the number of codes will grow from about 14,000 to more than 68,000.

Consider the example of a fracture of one or more phalanges of hand bones. In ICD-9, code 816.0 indicates closed, code 816.1 indicates open, and code 817.0 indicates a multiple fracture of the hand bones. You must append a fifth digit to these codes to indicate details, such as phalanges, unspecified, middle or proximal phalanx, distal phalanx, or multiple sites. Even if you attach a fifth digit to the codes, fewer than 20 codes exist for this condition.

In ICD-10, approximately 75 additional codes each require a seventh digit to indicate specific information such as initial encounter for closed fracture or subsequent encounter for routine healing. Specific categories exist for fracture of the thumb, unspecified phalanx, and specific finger and hand, for example, and additional subcategories indicate displaced and non-displaced specific portions of the finger, for example.

ICD-10 has far more codes than ICD-9. Initially, when the change to ICD-10 occurs, you will have to make a huge adjustment when determining the correct code that is needed. Whether providers are willing to learn all the new codes remains unclear.

You also must consider what will happen when the chart note is sent to another provider. Is it appropriate for that provider to have to review the codes to learn what disease a patient has, assuming he or she is not looking at a hospital chart? Will a provider be willing to do that?

Even if you have the best memory possible, you will find it very difficult to memorize the entire list of ICD-10 codes that your practice uses. Documenting with the exact disease nomenclature provides clarity for your staff as well as anyone else who reads the notes.

The author is president of Medical Coding & Reimbursement Management in Cincinnati, Ohio. Do you have a primary care-related coding question you would like to have our experts answer in this column? Send it to medec@advanstar.com
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© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health