REBUTTAL: Yes, Doctors are Required to Use Words

EDITOR’S NOTE: In the current e-news edition of RACmonitor, Chris Gallaher, a coder, takes issue with a June 23 article written for RACmonitor by healthcare attorney David Glaser, a longstanding member of the RACmonitor editorial board and popular panelist on Monitor Mondays. Gallagher faults Glaser’s position that there are no rules requiring physicians to use words to record a diagnosis in their documentation. Here is Glaser’s response:

Chris Gallagher disputes my conclusion that there is no requirement that a physician specifically use words, rather than codes, to record a diagnosis. 

There are only three binding sources of authority for Medicare: statutes, regulations, and National Coverage Determinations (NCDs). To accurately claim that that anything is “required” by Medicare, one must be able to cite at least one of those three authorities.   

The rebuttal includes no such citation. While Chris may feel that words are preferable, recommended, or even demonstrably superior, that is very, very different than “required.” Statements from trade groups, lawyers, consultants, and even Centers for Medicare & Medicaid Services (CMS) officials are not binding authority. 

Anyone is welcome to have an opinion about a particular practice. But it is important to understand that it is only an opinion. The difference between an “opinion” and a “requirement” can be the difference between keeping money or refunding it – or, more importantly, between freedom and prison. Chris Gallagher is welcome to write an opinion piece about the merits of using words rather than codes, as long as that is properly framed as an opinion, not mischaracterized as a requirement.