Diagnosis coding and documentation

Accurate diagnosis coding provides Priority Health with a snapshot of medical conditions affecting our member population.

  • Medical record documentation for a diagnosis must be clear, concise, consistent, complete, and legible.
  • Lab, pathology, or any other results used in diagnosing a condition should be available within the member's record.
  • Once you identify and document the most accurate diagnosis, we can provide members with information on maintaining a healthier lifestyle.

The guidelines below may or may not impact reimbursement for services rendered.

Diagnosis coding accuracy guidelines

Use the most current ICD-10 codes and code books, which are updated annually. This ensures you accurately report conditions and avoid unnecessary claim rejections.

Accurately document conditions that can be reported with combination ICD-10 codes. Use terms such as "due to" or "associated with" to create a clear and concise picture that these conditions are related, and an accurate diagnosis code can be assigned. Some diagnosis codes have guidelines that state "code also", which indicates that a second code should be listed to assist in identifying a specific condition.

  • Example: A member has congestive heart failure due to hypertension. If it is documented as "congestive heart failure and hypertension (CHF)" or "congestive heart failure, hypertension" there is no way to clearly identify that the conditions are related to one another.

Use the most specific diagnosis available. When there are multiple forms of a given diagnosis, document and select the exact code that identifies the condition. Avoid selecting a diagnosis for chronic bronchitis when the member actually has acute bronchitis. Avoid unspecified diagnoses, which may not support medical necessity and may result in claim denial.

  • Example: Don't report unspecific anemia diagnosis (D64.9) for a member with refractory anemia (D46.4) or agranulocytosis (D70.9), etc. Remember, the specific type of condition should also be documented in the medical record.

Use the "history of" Z code on diagnosis codes for conditions the member no longer has.

  • Example: When a member has been classified as cancer-free for a number of months/years, report the appropriate diagnosis code for the cancer preceded by Z to reflect that the member once had the condition but it is no longer considered current.

Documenting diagnoses

Your medical record is the support for your diagnoses. Documentation is especially critical when selecting diagnosis codes that require additional digits.

Document and report co-existing conditions

Include all conditions that co-exist at the time of a visit and impact the member's treatment plan or management of their care. Do not report conditions that previously existed but are no longer being treated.

Avoid unconfirmed diagnoses

Avoid terms such as "probable", "suspected", or "rule out." Base your diagnosis code on a high level of certainty relating to the member's current signs and symptoms.

Document the confirmation of a diagnosis

Identified by pathology reports, radiology reports, etc. Review the information supplied and report the confirmatory diagnosis in the member's medical record. Although a lab report or radiology may indicate a condition, it is up to the provider of care to confirm that the condition exists.