When is it appropriate to use other clinicians' documentation to record a diagnosis?

A 2019 Official Coding Guideline update addressed using other providers’ documentation for assignment of specific diagnosis codes.  This installment of “In the kNOW” explores when it is appropriate to use the documentation of clinicians in a patient’s record to record a diagnosis.

Previously, the Official Coding Guidelines outlined several “qualifiers” of conditions where it was acceptable for coding professionals to use documentation by a clinician to capture the code.  These “qualifiers” include:

• BMI
• NIHSS
• Coma scale
• Depth of non-pressure chronic ulcers
• Stage of pressure ulcers

The same guideline (I.B.14) shared that the patient’s provider, who is considered their physician, or other healthcare practitioner legally accountable for establishing the patient’s diagnosis, must be the one who documents the associated diagnosis, such as obesity, stroke, or pressure ulcer.  Since the “qualifiers” listed above provide more detail regarding the diagnosis established by the provider, it is acceptable to utilize the documentation of a clinician such as a dietitian for the BMI, a nurse for pressure ulcer stage, or even an emergency medical technician for the coma scale.

With the 2019 Official Coding Guideline update, we see that the previous title of this applicable guideline changes from “Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale” to “Documentation by Clinicians Other than the Patient's Provider”.  While all the above information remains under this guideline, a new section has been added which addresses code assignment for social determinants of health. 

Codes for social determinants of health are found in categories Z55-Z65.  This section is entitled “Persons with potential health hazards related to socioeconomic and psychosocial circumstances”.  Within this section, coding professionals find codes that identify the following:

• Problems related to education/literacy
• Z55.3 Underachievement in school
• Problems related to employment/unemployment
• Z56.2 Threat of job loss
• Problems related to housing and economic circumstances
• Z59.0 Homelessness
• Problems related to upbringing
• Z62.1 Parental overprotection
• Problems related to other psychosocial circumstances
• Z65.2 Problems related to release from prison

These are just a few of the areas and codes represented in this section. 

The rationale for being able to use the clinician documentation to assign these codes is that they are not medical diagnoses but rather they reflect social information.  Additionally, this point is echoed in ICD-10-CM/PCS Coding Clinic, First Quarter 2018 pg: 18.    

A further Official Coding Guideline update involves the coding of BMI at I.C.21.c.3.  Coding professionals are instructed not to code the BMI unless a related diagnosis of overweight or obesity is documented by the provider and meets the definition of reportable diagnosis.  The same update states that BMI is not to be coded for pregnant patients. 

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.