Coding corner update: Improve medical record documentation by using accurate diagnosis codes

Beginning Oct. 1, 2015, the transition to ICD-10-CM will affect every area of health care. Many codes contain much greater specificity. This article includes updated codes to align with the transition to ICD-10-CM.

Accurate diagnosis code selection plays a critical role in communicating a patient’s health status to Blue Cross Blue Shield of Michigan for many purposes, including Medicare risk adjustment, quality measures, government programs and various incentive programs. However, reporting the proper diagnosis code is only possible if progress notes for the patient progress have complete and accurate documentation to support each condition.

Here are answers to some frequently asked questions to help ensure a diagnosis is properly substantiated through medical record documentation.

How often should a chronic condition be reported on a claim?
Each patient’s chronic conditions should be reported at least once a year as part of a face-to-face encounter. Providers aren’t required to report all of a patient’s chronic conditions on every claim. Instead, document chronic conditions as often as they’re assessed or treated.

What are the documentation requirements?
Each reported diagnosis must be validated by the documentation in the progress note for that specific date of service.

The progress note must document how the condition was managed, evaluated, assessed or treated, also known as MEAT. At least one component of MEAT must be documented for each condition.

• Manage: Indicate order of labs, diagnostic radiology or other tests.
• Evaluate: Document review of lab or X-ray results and pertinent exam results.
• Assess: Describe the status of a patient’s condition (stable, worsening or improved).
• Treat: Indicate if medications are prescribed or refilled, and any surgical treatments or therapy services performed.

Additionally, each progress note should link the documented MEAT components to a specific diagnosis to make the treatment plan for each condition clear to the coder.

What if a diagnosis isn’t clearly documented?
Providers should report the ICD-10-CM code that identifies the patient’s condition to the greatest specificity. However, documentation in the progress note must support this specificity by explicitly identifying the diagnosis, and the diagnosis can’t be inferred.

For example:

• If diagnosis I20.0 is reported on a claim, documentation must specify unstable angina, not just angina or chest pain.

• If I50.32 is reported on a claim, documentation must specify chronic diastolic heart failure, not congestive heart failure.

Terms such as “rule out,” “consistent with,” “possible” or “probable” should be used with caution if you’re trying to substantiate a diagnosis. These terms indicate the diagnosis isn’t definitive and consequently can’t be coded as if the condition exists in the outpatient setting.

Should the MEAT components and treatment plan be linked to the specific diagnosis or will an auditor infer the connection?
A coder can’t infer that orders and results are related to a specific condition. Providers should interpret results and link all tests and orders to a specific condition.

For example, a coder can’t assume that a lipid panel is being ordered to address a patient’s hyperlipidemia if the patient is being treated for other chronic conditions.

Always link medications to a specific diagnosis and indicate if the medication is new, to be continued or to be discontinued, and make sure to indicate the specific dose.

For example, a statement such as “continue current meds,” won’t validate a diagnosis. Instead you should say “diabetes, stable. Continue Metformin 850 mg once daily.”

Each diagnosis should have its own individual treatment plan that indicates tests ordered, referrals made, patient instructions and when the next patient visit should be scheduled.

What are correct linking words to indicate a manifestation or complication of a condition?
A cause-and-effect relationship between a condition and its manifestations may not be assumed. The relationship should be documented with correct “linking” words in the progress note. Here are some examples of how you can code for diabetes:

• End stage renal disease secondary to diabetes
• Ulceration caused by diabetes
• Polyneuropathy due to diabetes
• Diabetic polyneuropathy

Note: The term "with" isn’t an acceptable linking word in medical record documentation to demonstrate causality between two conditions. See the September 2013 Record article for more information.

Blue Cross has two resources available on web-DENIS to aid providers in accurate documentation and coding:

• BCBSM Coding Initiativepresentation (available in text or audio)
• Documentation and Coding Tips for Professional Offices, a set of tip cards

Follow these steps to locate the training aids on web-DENIS:

• Log onto web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Click on Medicare Advantage Resources. The two training documents are located on this page.

Additional resources are available on the Blue Cross ICD-10 website at bcbsm.com/providers/help/faqs/icd-10.html.

If you have questions or need more information, contact your provider consultant.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.