The One Coding Rule I’d Rewrite if I Could
Article Reference Code: NAMAS.05.15.2026
Written by: Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC
“But I documented it yesterday. Why do I have to say it again? Why can’t you just look at my other notes?”
Most of us have heard those words and have tried to explain the need for physicians to document information again. In this one instance, I sometimes agree with the physician—or at least sympathize with the frustration. This is the one coding rule I would rewrite if I could.
For clinical purposes, physicians and staff can review the medical record to find previous lab results or determine which leg was broken in 2016. For coding purposes, however, we can assign diagnosis codes only for conditions documented on the date of service by the physician. For each encounter, we must follow the guideline to “code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment, or management.” How do we know what affected care on that date of service if the physician did not document it? (ICD-10-CM Official Guidelines for Coding and Reporting, Section IV.J.)
There is an allowance for laterality documented by someone other than the physician, and there are a few other exceptions. (See ICD-10-CM Official Guidelines for Coding and Reporting, Section I.B.14.) But for the most part, we cannot use clarifying information from another encounter or date of service. If I want to code more specifically, why can’t I look at a previous note to see whether the information is there? Why do I have to code unspecified heart failure today when I know the patient had an echocardiogram last month and the physician documented the ejection fraction, which provides more specific information? Because that is the rule.
We can use previously documented information to craft a query to the physician, but then we must wait for the provider’s response and make sure the updated information is entered into the medical record. Queries may become part of the medical record, but that is not required and depends on practice policy. In most cases, we are asking the physician to answer the question and update or amend the record. Many physician practices may not even have a query process or policy, which is a topic for another day.
Remember, too, that we cannot code from patient history or medication lists. In many cases, problem lists are indeed problems. This lack of specificity in documentation can also affect CPT code selection, especially when diagnosis information drives code choice.
So how would I rewrite this rule? I would set parameters for where we could look for additional or clarifying information. It would need to be documented by that provider or by a partner in the same specialty. It would need to fall within a defined time period, and there would have to be no contradicting information. We could move from an unspecified diagnosis to a more specific one, but not to a more specific diagnosis that conflicts with the current documentation.
I code for a group of neurosurgeons, and one area of ambiguity involves stenosis with or without neurogenic claudication. Neurogenic claudication is not something that usually resolves from day to day without surgical intervention. The office note says “with neurogenic claudication,” but the operative report does not specifically state it, so the surgery must be coded as “without,” which can create medical necessity issues.
Under my ideal rule, if the physician documented a more specific diagnosis on Day 2 of a hospital stay, that information could be used from Day 2 forward, but it would not apply to services on Day 1. If Day 3 reverted to a nonspecific diagnosis, we could look back to Day 2 for clarification. Even for inpatient services, physician coding is day by day. Each encounter must stand on its own. What is documented on Day 1 supports the coding on Day 1.
This could have implications beyond coding and billing. I was involved in a case in which malpractice allegations were made because the physician, or the coder in their office, billed the final diagnosis on every day of the hospitalization. The plaintiff’s attorney argued that this suggested the physician knew what was wrong immediately after admission but delayed treatment for several days, ultimately resulting in the patient’s death.
But perhaps my rewritten rule would be too cumbersome, with too many exceptions and requirements. It would also require a level of clinical, specialty-specific knowledge that coding professionals should strive for but may not yet have.
For now, this rule reinforces a bigger principle: accuracy over assumption. Coding professionals must carefully review each encounter to ensure that every diagnosis, procedure, and level of service is supported by current, complete documentation.
In a field where precision matters and assigned codes live forever, previous documentation is context, not justification. The patient deserves a complete and accurate story documented at every encounter.
Contact Kim on LinkedIn by Clicking her Name Below:
Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, COC
Kim is an independent coding and reimbursement consultant, providing audit, training and oversight of coding and reimbursement functions for physicians. Kim completed three years of pre-medical education at the University of Alabama before she decided that she preferred the business side of medicine. She completed a Bachelor’s degree in Health Care Management and went on to obtain certification through the American Academy of Professional Coders and the American Health Information Management Association. Recognizing the important position of compliance in today’s health care environment, she has also obtained certification as a Certified Professional Compliance Officer and has earned a Master of Jurisprudence in Health Law. Kim is also an AHIMA-approved ICD-10-CM Trainer and a member of the AHIMA Coding Community Task Force. She has authored articles for the Journal of AHIMA and the Health Care Compliance Association.
For thirty years, Kim has worked with providers in virtually all specialties, from General Surgery to Obstetrics/Gynecology to Oncology to Internal Medicine and beyond. She has spoken at the national conference of the American Academy of Professional Coders, the American Health Information Management Association, the Health Care Compliance Association, the Ingenix Essentials conference, Part B News’ Medicare Billing 101 and has presented audioconferences for AHIMA, DecisionHealth, The Coding Institute, Coding Leader, Intelicode, and Progressive Healthcare.
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