Best Practices: Documenting the Diagnosis in Clinical Record Keeping

The clinical record must contain documentation of the physician’s assessment of the patient’s condition that is being treated.

Documenting the Diagnosis
The diagnosis itself must be consistent with and supported by the patient’s presentation and the examination and laboratory findings. Initially the diagnosis is often only the diagnostic impression or working diagnosis. On follow-up visits the diagnosis should be confirmed as the clinical thought process continues.

Documentation of return follow up visits (usually in the “A” portion of the SOAP note) must include a statement of the diagnosis that reflects changes in the patient’s condition as a response to time, treatment, and other interim events (e.g., “Cervical strain, resolving” or “fatigue, improving”). The “A” should be updated as necessary to be an accurate portrayal of the patient’s present condition.

Diagnosis codes used on a health insurance claim form must be supported by the information in the patient clinical record.

ICD-9-CM
The International Classification of Diseases (ICD) is designed to promote international comparability in the collection, processing, classification, and presentation of mortality statistics. The ICD-9 was published by the World Health Organization in 1977. The National Center for Health Statistics created an extension of ICD-9 so the system could be used to capture more morbidity data. This extension was called “ICD-9-CM”, with the CM standing for “Clinical Modification”. The International Classification of Diseases, Clinical Modification (ICD-9-CM) is based on the ICD-9 but is used in assigning codes to diagnoses associated with inpatient, outpatient, and physician office utilization in the U.S. Every health condition can be assigned to a unique category and given a code from ICD-9-CM.

ICD-10-CM
Transition to ICD-10-CM will occur October 1, 2015. Most, but not necessarily all, payers will stop accepting ICD-9 codes and start accepting ICD-10 codes. The diagnosis codes in ICD-10 are more specific and more detailed. For example, left and right side conditions (e.g. extremity conditions) are now two different diagnoses. And there are different diagnoses for certain conditions seen at an initial encounter, in follow up “subsequent” encounters and as a sequela. As with ICD-9 codes, the clinical record must support the code used to document the condition or as used on an insurance claim form.

Note: Some integrative healthcare providers are prohibited by law from making a differential diagnosis. Therefore, this “best practice” recommendation may not apply to acupuncture or massage therapy. However, many diagnosis codes in both ICD-9 and ICD-10 are symptoms only and do not imply that the provider has made a “differential diagnosis.” For example, “neck pain/cervicalgia” is 723.1 (ICD-9) and M54.2 (ICD-10)