Guidelines › Documentation by clinicians other than the provider
Documentation by clinicians other than the provider
Official text from the FY2027 ICD-10-CM Official Guidelines for Coding and Reporting. The wording is quoted exactly.
Guidelines I.B.14
“This information is typically, or may be, 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.”
“The BMI, coma scale, NIHSS, blood alcohol level codes, codes for social determinants of health and underimmunization status should only be reported as secondary diagnoses.”