Who can change a diagnosis code?

A diagnosis code can be changed or modified in two distinct contexts: the official modification of the code sets themselves and the correction or update of a diagnosis code on a patient's medical record.

Understanding "Changing a Diagnosis Code"

The phrase "changing a diagnosis code" can refer to two very different processes, each involving different entities and purposes.

Changing the Official ICD-10 Code Set

This refers to the formal process of adding new codes, deleting obsolete ones, or revising existing descriptions within the standardized classification systems, such as the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). These changes affect the list of available codes.

Changing a Diagnosis Code on a Patient's Record

This pertains to the act of assigning, correcting, or updating a specific diagnosis code used for an individual patient's medical encounter, billing, or health record. This is about ensuring the code accurately reflects the patient's condition and the services provided.

Modifying the Official ICD-10-CM Diagnosis Code Set

The official ICD-10-CM diagnosis codes, which are used across the U.S. healthcare system, undergo a formal review and update process. Suggestions for modifications to these codes can originate from various sources within both the public and private sectors.

The primary lead for all matters concerning ICD-10-CM diagnosis issues rests with the CDC's National Center for Health Statistics (NCHS). For procedural codes (ICD-10-PCS), the Centers for Medicare & Medicaid Services (CMS) takes the lead. These federal agencies work in conjunction with the ICD-10 Coordination and Maintenance Committee, a federal committee responsible for maintaining and updating the code sets.

Key participants in modifying the official code set include:

• CDC's National Center for Health Statistics (NCHS): Holds the lead for diagnosis code issues.
• Public and Private Sectors: Submit suggestions for new, revised, or deleted codes. This can include professional medical organizations, healthcare providers, and industry stakeholders.
• ICD-10 Coordination and Maintenance Committee: A federal body that reviews proposed changes and makes recommendations for updates to the code sets.

These modifications are typically incorporated into annual updates, ensuring the code sets remain current with medical advancements and public health needs.

Correcting or Updating a Diagnosis Code on a Patient's Medical Record

When it comes to the specific diagnosis codes applied to a patient's medical record for clinical documentation, billing, or insurance claims, the responsibility for establishing and changing these codes lies with licensed healthcare professionals and those who work under their direct supervision.

Who can change a diagnosis code on a patient's record:

• Licensed Healthcare Providers: The physician or other qualified healthcare professional (e.g., Nurse Practitioner, Physician Assistant) who rendered the care is ultimately responsible for establishing the diagnosis and ensuring it is accurately documented. They are the only ones who can officially change or correct a diagnosis that has been assigned to a patient's record, as it reflects their clinical judgment and findings.
• Certified Medical Coders: Medical coders assign diagnosis codes based on the provider's detailed clinical documentation. If a coder identifies a discrepancy or needs clarification, they will query the provider. Coders can update a code upon receiving corrected or additional documentation from the provider.
• Billing Specialists and Auditors: In some cases, billing specialists or auditors reviewing claims might identify potential coding errors that require correction. However, any change to the diagnosis itself (which impacts the code) must be approved or directly made by the responsible licensed healthcare provider.

Practical Insights:

• Documentation is Key: All diagnosis codes must be supported by clear, thorough, and accurate documentation in the patient's medical record. If documentation is insufficient, the code cannot be assigned or may need to be changed to reflect what is supported.
• Reasons for Change: Diagnosis codes on a patient's record may be changed due to:
  • New information: As a patient's condition evolves or more diagnostic tests are performed, a preliminary diagnosis may be refined or changed.
  • Correction of error: A mistake in documentation or coding may be identified.
  • Clarification: Ambiguous documentation might lead to a query to the provider, resulting in a more precise code.
• Audit Trails: Any changes to medical records, including diagnosis codes, must be made in a way that creates an audit trail, showing who made the change, when, and why. This ensures integrity and compliance.

Importance of Accurate Diagnosis Coding

Accurate diagnosis coding is critical for several reasons:

• Patient Care: It provides a clear picture of a patient's health status and history, guiding future treatment decisions.
• Billing and Reimbursement: Correct codes are essential for healthcare providers to receive appropriate payment for services rendered.
• Public Health: Aggregated diagnosis data is vital for tracking disease prevalence, managing outbreaks, and allocating public health resources.
• Research and Statistics: Accurate data supports medical research, healthcare planning, and statistical analysis of health trends.