Documentation by Clinicians Other than the Patient's Provider

Service and Diagnosis code assignment is based on the documentation by the patient’s provider (i.e., physician or other qualified healthcare practitioners legally accountable for establishing the patient’s diagnosis). There are a few exceptions when code assignment may be based on medical record documentation from clinicians who are not the patient’s provider. 

In this context, “clinicians” other than the patient’s provider refer to healthcare professionals permitted, based on regulatory or accreditation requirements or internal hospital policies, to update or document a patient’s official medical record.

These exceptions include codes for:

• • Body Mass Index (BMI)
• • Depth of non-pressure chronic ulcers
• • Pressure ulcer stage
• • Coma scale
• • NIH stroke scale (NIHSS)
• • Social determinants of health (SDOH)
• • Laterality
• • Blood alcohol level
•  

This information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, pressure ulcer, or a condition classifiable to category F10, Alcohol-related disorders) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.

The BMI, coma scale, NIHSS, blood alcohol level codes, and codes for social determinants of health (SDOH) should only be reported as secondary diagnoses.

Any member of a person’s care team can collect SDOH data, to be documented in an individual’s health care record, during any encounter. This includes managers, patient navigators, and nurses.

ICD-10-CM Official Guidelines for Coding and Reporting FY 2022 (October 1, 2021 - September 30, 2022)