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Ensure compliance when coding nonphysician documentation

HIM Connection, April 28, 2009

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In most cases, coders should not assign codes based on documentation that does not come from a physician. Nonphysician documentation includes paperwork such as lab reports and nurse and social worker notes. Instead, coders should base code assignment on documentation provided by the qualified healthcare practitioners who are legally responsible for establishing a patient’s diagnosis. Coding Clinic, fourth quarter 2005, as well as state laws and hospital bylaws, offer guidance about the subject. Qualified healthcare practitioners typically include physicians and midlevel providers such as nurse practitioners and physician assistants.

In certain circumstances, when specific criteria are met, coders can code based on nonphysician documentation. For example, guidance from Coding Clinic, fourth quarter 2008, clarified that for body mass index (BMI) and pressure ulcer stage, coders could use notes from a dietitian and a nurse, respectively. However, these are exceptions rather than the rule. The Coding Clinic, fourth quarter 2005, which first allowed coders to use documentation from a dietitian to code BMI, states, "This is an exception to the guideline that requires that code assignment be based on documentation by the physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis."

Editor’s note: This tip was adapted from the April issue of Briefings on Coding Compliance Strategies.

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