Documentation from Other Clinicians

Per Official Guidelines for Coding and Reporting, there is updated guidance in section I.B.14. “Documentation by Clinicians Other than the Patient’s Provider”. This updated guidance states that medical coders may capture diagnosis codes based on medical record documentation from clinicians who are not the patient’s provider. In these instances, documentation from clinicians (such as dietitians, nurses, or emergency medical technicians just to provide a few examples) may provide more specific information that is missing in the attending provider’s notes. For example, if the attending provider documents that the patient has morbid obesity but does not include the body mass index (BMI), then it is appropriate to capture the BMI code assignment if it is located elsewhere such as in the dietitian’s documentation. However, if the attending provider did NOT document morbid obesity, then it is NOT appropriate to capture the associated diagnosis (morbid obesity) from the dietitian’s documentation. That diagnosis must be documented by the patient’s provider. Whenever there is conflicting documentation from the patient’s provider and other clinicians, then the patient’s provider must be queried for clarification.