ICD-10-CM Official Guidelines for Coding and Reporting FY 2017
Have any of you had the chance to look at the new FY 2017 Coding guidelines? There is a new heading under Section I. A. #19. Code Assignment and Clinical Criteria "The assignment of a diagnosis code based on the provider's diagnostic statement that the condition exists. The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis." Thoughts ?
Comments
There was a discussion regarding this on this weeks Talk Ten Tuesday. I didn't get to listen live but listened to the podcast. If you aren't already subscribed, you should be able to do so @ www.icd10monitor.com
It is a very interesting guideline that causes a "catch 22" as Allen Frady points out on the podcast. I think we need more guidance from the cooperating parties and hope to see something issued very soon. If not, then I guess it's up to the individual organizations to decide if they are going to continue to issue clinical validation queries or "anti" queries as some call them.
Definitely a topic to watch!
Jeff
Cheryl
I actually like this new guideline. I think the guideline is basically just reiterating that coders are not clinicians and they (and us) are not in the business of validating dx and deciding which documented dx are including in the coding summery. When a physician states a dx, the default it that it should be coded. The caveat is that if clinical indicators are not present, we can clarify (and we should) to determine if the physician would like to confirm the dx made or select a more appropriate dx.
I have a relevant example: One of our contract coders recently informed me that she was being guided by her auditor that when sepsis 2/2 pancreatitis or cholecystitis was documented, sepsis should not be coded unless they specifically stated that the pancreatitis/cholecystitis was infectious. This is because these conditions are generally noninfectious (her words, not mine. I agree pancreatitis is rarely infectious but there is often an infectious component to cholecystitis). I disagree. If the physician states sepsis 2/2 chole we have two options. Either we code the sepsis and cholecystitis, or (if clinical indicators do not support sepsis), we query for clarification. I actually quoted this guideline in response. Same with new SOFA guidance. We cannot just opt not to code sepsis when documented if it doesn't meet Sepsis-3. Our doctors make the dx. The most we can do is query when we think the diagnosis does not have sufficient clinical indicators.
I think there has been a recent push for coders to determine when a dx is correct. this is outside of scope and inappropriate. Facilities (and individual coders) can not create clinical criteria by which a condition will/wont be coded. If physicians say it, it must be coded or clarified. Physicians are the diagnosticians and it is on them to make appropriate and well supported dx. It is the coders job to translate the dx into the code set. It is CDI's job to ensure that proper terminology and specificity is included in the documentation so that the most accurate code can be applied. I think this guidance is just confirming what we have always known.
Our coders are very excited about this new guideline but....it still states:
"For reporting purposes the definition for “other diagnoses” is interpreted as additional conditions
that affect patient care in terms of requiring:
clinical evaluation; or
therapeutic treatment; or
diagnostic procedures; or
extended length of hospital stay; or
increased nursing care and/or monitoring."
So this will be their argument when it comes to denials. I'm interested to see how this plays out.
Good points Katy, I believe we will continue clinically validating dx's and things will be business as usual.
Jeff
There is an article in today's CDI Strategies that refers to a new Practice Brief in the July issue of the Journal of AHIMA - Clinical Validation: The Next Level of CDI.
Thanks,
Donna