As per ICD10-CM Official Guidelines, your choice of diagnosis code is based on the actual diagnostic statement provided by physician. But it depends on case to case basis.
The Official Guideline Wording
The 2019 ICD-10-CM Official Guideline (OG)
Coder always assigns code based on the provider’s diagnostic statement. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not always based on clinical criteria used by the provider to provide the diagnosis.
You can consider that the medical coding is depends on provider documentation because the provider is the one who responsible for diagnosing the patient.
Coders may confuse when that the documentation for the case does not support current clinical criteria for the diagnosis that the provider records.
While starting coding first point should be this: “While physicians may use a particular clinical definition or set of clinical criteria to establish a diagnosis, the code is based on his/her documentation, not on a particular clinical definition or criteria.” This quote is from AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS (2016, vol. 3, no. 4).
If clinical validation reviewer disagrees with the provider’s diagnosis then this is not a coding issue, this is a clinical issue.
Coders should follow one important guideline that they should not code sepsis in the absence of physician documentation.
Coding tips: When severe sepsis is documented, there will be a minimum of two codes when using ICD-10-CM: a code for the underlying systemic infection, followed by a code for severe sepsis, R65.2-. If organ dysfunction other than septic shock is present, the codes for the specific organ dysfunction are added.
Coder should always keep in mind that the basic rule of coding is to assign codes based on the provider’s diagnostic statement. But as we discuss above this is not always possible. Consider case of experienced coder who has been working in specialty for many years. If he or she cannot follow how a doctor got to the final diagnosis based on what’s documented, then it’s possible an auditor for a payer won’t be able to follow it either. Consider in this case that the auditor may determine that payment was inappropriate, meaning the payer will demand the money back. Such documentation may lead to legal cases, too.
So, conclusion is that it’s an organization’s responsibility to have a clear process for handling documentation that seems to not support the final diagnosis. Everyone has to know their own role clearly defined be it coder, documenting provider and possibly a provider assigned to be the reviewer in such cases.
We suggest you to hire coder from us or outsource your medical coding process to us for better process. We have clear transparency in our reporting to physicians. We have very experienced and certified medical coding staff with defined coding process.
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