Is the ICD-10-CM code enough?

Question:

I am reaching out to ask if a provider lists the ICD-10-CM code with code description on the encounter under the Assessment and Plan if this is sufficient to use as their documentation and would this pass in an audit?

I do not believe this meets the ICD-10-CM guidelines and would like some clarification that I'm not querying erroneously.

Thank you in advance for your response to this matter!

Answer:

Thank you for your query, it is a great question.

No, it is not sufficient for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement. The AHA coding clinic, specifically the 4th quarter of 2015, states that the ICD-10 codes are "statistical classifications, not replacements for a provider's written diagnosis."

*This response is based on the best information available as of 01/08/26.