Q&A: Coding diagnoses from physician orders

Q: Our coding and CDI team have been discussing coding diagnoses from physician orders recently. This topic comes up occasionally and I am curious as to what other systems are doing in this space. We are aware of the older Coding Clinic from Third Quarter 2005 (pp. 19–20). Does anyone have any more up-to-date advice on physician orders/coding of diagnoses?

A: Great question and one that we do often get asked. Indeed, you can report conditions documented in the physician orders, as noted in the Coding Clinic you referenced and the Official Guidelines for Coding & Reporting Section I.A.19 which states:

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider.

Sometimes coders will state that you cannot report from the orders, just as you might hear a coder say that if a diagnosis is not listed in the assessment, it cannot be reported, but this is not what the guidance states. Such statements may have grown from organizational policies (both official and unofficial) that have been passed down year after year.

We as CDI professionals need to understand that we are likely the only professionals who read the entire record, including the orders. We do this because it is a gold mine of clinical indicators and offers us a lot of information to work with. The coder, working under strong productivity measures, likely does not review the orders to that level of detail, as other areas of the record (e.g., history and physical  and discharge summary) offer more value in identification of the reportable conditions.

I would suggest that CDI and coding leadership work together to internally define which documentation within the medical record allows a diagnosis to be reported. Of course, your internal definition cannot stray outside the boundaries defined by the Guidelines and Coding Clinic instructions. An organization, however, can choose to interpret those guidelines more conservatively.

If, together, you conclude the orders can be used, CDI staff should clearly identify the location (date/time/who documented) in their notes so that the coders do not have to hunt the information down.

Editor’s note: Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, the CDI education director at HCPRo and interim director at ACDIS answered this question. Contact her at laurie.prescott@hcpro.com.