ICD-9 Coding in the Urgent Care Center

Question: Recently, we received the following question about urgent care ICD-9 coding.

A nursing supervisor through our parent hospital is questioning the ability of an MA to legally write in ICD-9 codes matching physician diagnoses. It is my understanding that MAs get this training in school and as long as the physician is assigning the diagnosis and E&M code, the MA (certified MAs) can write in an ICD-9 code which directly matches. It has been this way in all offices I have worked in. If you have any like or something in writing supporting this, please let me know.

Answer: The physician is ultimately responsible for all codes billed out for all professional services billed under the physician’s provider number. There are many ways, however, for the facility to do this.

  1. Have staff assign the codes, and require the physician to initial the final codes.
  2. Force physician to assign all codes.
  3. Have staff assign the codes (after physician writes down the diagnosis), but have physician do audits of randomly selected charts on a regular basis to make sure that, for compliance reasons, the physician agrees with the codes being chosen.
  4. Use checkboxes on a form so the physician can assign the majority of codes. If this is combined with a commercially available “cheat sheet” of most common codes, over 90% of the ICD-9 codes can be readily assigned by the physician, without slowing down the process.
  5. There are probably other compliant methods for ICD coding in the urgent care center.
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