The symptoms of poor clinical indications in professional coding

July 19th, 2019 / By Allison Morgan, MS, CPC

During a recent webinar I attended, participants were asked about their biggest documentation challenge as professional coders. Almost half of the attendees reported that vague or absent language in the clinical indication for the diagnostic study was their greatest obstacle.

Given the changing environment facing many practices, this struggle is not a surprising one. As departments attempt to create a more streamlined process, the use of HIS, RIS and EMRs allow information related to a patient to be entered by various individuals involved in the encounter. This means disconnects can take place in the workflow. Clinical indications for diagnostic studies are often entered or documented by a tech or ordering physician independently of the diagnostic facility or practice. If this results in poor documentation for diagnostic studies and an absence of definitive findings for the study, it becomes the coder’s albatross. 

Section 1.B.4 of the ICD-10-CM Official Guidelines for Coding and Reporting FY 2019 establishes that “…symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.” For coders coding diagnostic reports, this is a common outcome. In the absence of definitive findings, the clinical indication or reason for the exam becomes the fundamental source for primary coding.

To ensure strong documentation around indications, remember these key points:

  • Educate orderings and techs on the importance of clear and concise language in the indication. Time constraints (especially in hospitals) and a patient’s conditions may limit the quality of documentation related to the indication. It’s important to remember, however, that the documentation they provide may ultimately become the primary driver of the codes selected.
  • Avoid documenting rule-out language. Signs and symptoms should be documented. This is especially important when trying to rule out a condition. While rule-out codes are available to coders, the specificity behind them is limited and does not allow a full picture of the patient’s symptoms that warranted the diagnostic study. Keep in mind that payers are often looking to establish medical necessity, including at the indication level.
  • For diagnostic studies, document those indications that are relevant to the exam. This allows documentation to remain concise and relevant to the study.
  • Avoid abbreviations. Documentation should stand on its own and a word or phrase should not be assumed.
  • If the patient is symptomatic with associated external causes, be sure to document these. They will provide important context behind the cause of the condition or necessity of the encounter.

Clinical indication language and codes not only set the stage for why a patient needed a study, but establishes a clear medical record, often decides payer reimbursement, establishes medical necessity for treatment  and can contribute to accurate reporting for quality measures or population and medical studies.  It’s important to remember that when no reason for an exam is present or the documentation is limited, the effects are far reaching. As different individuals enter documentation within the clinical and medical record, it’s essential to maintain quality documentation best practices so a clear reason for the exam is established. 

Allison Morgan is a clinical development analyst at 3M Health Information Systems.