Documenting your patients’ clinical conditions is an extremely tough, but important process. The CMS and commercial payers require you to indicate the desired medical necessity in a maximum level of detail in the medical records and on insurance claims of each patient. The latter process includes code assignment, i.e. choosing an appropriate ICD-10 diagnosis code to indicate a specific clinical condition. In most cases, healthcare providers must use their own assessment results and clinical documentation when choosing an applicable ICD-10. However, sometimes the CMS allows you to select and report diagnoses based on medical records prepared by a different provider. This exception normally covers the information documented by other clinicians involved in a patient’s treatment course, for example, dietitians. According to the CMS guidelines, the following aspects may be retrieved from clinical charts done by a different healthcare professional:
o Body Mass Index (BMI)
o Depth of non-pressure chronic ulcers
o Pressure ulcer stage
o Coma scale
o NIH stroke scale (NIHSS)
o Social determinants of health (SDOH)
o Laterality
o Blood alcohol level
The BMI, coma scale, NIHSS, blood alcohol level codes, and codes for social determinants of health are considered to be secondary indicators, hence they cannot be reported without an associated primary diagnosis. This diagnosis cannot be taken from other clinicians’ documentation. For example, BMI can be reported with E66.9, which stands for obesity, provided that this diagnosis comes from the reporting physician’s assessment.
At WCH Service Bureau, we strive to keep our clients informed on the most up-to-date reimbursement policy changes and clinical documentation guidelines. Our team of certified professional billers & coders will be happy to handle your medical billing.
