Diagnoses Must be Clinically Validated/Treated in Order to be Coded

sbourque

I need to find in the official coding resources (official coding guidelines and/or coding clinic) the guidance to use clinical validation before assigning codes. I have seen documentation in CMS MLN matters SE1121 and other publications that confirms this but I cannot find anything in Coding Clinic or the OCG that supports this. If anyone can cite some official sources for me, I would really appreciate this.
thanks

katysuegood@gmail.com

I haven’t noticed anything in the conventions/guidelines about the need for it to be clinically valid, just that it must meet UHDDS (evaluation, treatment, procedures, extend LOS, Impacts nursing case, Monitoring). But it is ion the AHIMA/ACDIS query brief.

I think the biggest issues is denials. Even if it is appropriate to code it based on MD documentation, dx that are not clinically validated int eh record are at risk for denial, and may simply be inaccurate.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404


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Subject: [cdi_talk] Diagnoses Must be Clinically Validated/Treated in Order to be Coded

I need to find in the official coding resources (official coding guidelines and/or coding clinic) the guidance to use clinical validation before assigning codes. I have seen documentation in CMS MLN matters SE1121 and other publications that confirms this but I cannot find anything in Coding Clinic or the OCG that supports this. If anyone can cite some official sources for me, I would really appreciate this.
thanks
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evanspx@sutterhealth.org

CMS MLN matters SE1121 is an official publication issuing directions on coding practice, and, as you stated, provides guidance that an issue is required in some case to ensure clinical validity.


2013 ACDIS/AHIMA guidance titled “Guidelines for Achieving a Compliant Query Practice” states “generation of a query should be considered when health record documentation ... provides a diagnosis without underlying clinical validation.” In addition, the brief states:
“The focus of external audits has expanded in recent years to include clinical validation review. … When
a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in
The health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation policy.”

MLN Volume 1, issue 4, July 2011, Published by CMS – Advises a Coder to Query the MD for Acute Respiratory Failure that is clearly stated on multiple occasions.



An 81-year-old female was admitted with complaints of dry cough for a couple of weeks. The patient was admitted through the emergency department and was assessed for wheezing and coughing. H&P impression is acute respiratory failure secondary to exacerbation of Chronic Obstructive Pulmonary Disease (COPD). Progress notes through the stay also document the diagnosis of acute respiratory failure secondary to exacerbation of COPD. Final diagnosis on the discharge summary is acute respiratory failure secondary to COPD exacerbation. Additional documentation sheet supplied in the record list the patient's diagnoses as: Principal Diagnosis: COPD exacerbation; Other Diagnoses: high blood pressure, Coronary Artery Disease (CAD), Congestive Heart Failure (CHF), Diabetes Mellitus (DM), Parkinson's, and rheumatoid arthritis.

Auditor finding: After physician and auditor review, it was determined that the clinical evidence in the medical record did not support respiratory failure, despite physician documentation of the condition.

Action: The auditor deleted acute respiratory failure and changed the principal diagnosis to COPD Exacerbation. The auditor deleted respiratory failure code 518.81 and changed the principal diagnosis to hypoxemia code 799.02. This resulted in a MS-DRG change from 189 to 192–Chronic Obstructive Pulmonary Disease without CC/MCC. This change resulted in an overpayment.

Guidance on How Providers Can Avoid These Problems:

✓ The condition chiefly responsible for a patient’s admission to the hospital should be sequenced as the principal diagnosis, and the other diagnoses identified should represent all CC/MCC present during the admission that affect the stay. Code only those conditions documented by the physician.

✓ Refer to the coding clinic guidelines and query the physician when clinical validation is required.

fishdl@shands.ufl.edu

Hope this helps,

Donna Fisher, CCS, CCDS, CHC
UF Health Shands

sbourque

Thanks all, very helpful ! I’ve got some battles to fight…

evanspx@sutterhealth.org

Is not fighting battles in all of our job titles and duties? ☺

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421



evanspx@sutterhealth.org