Code Assignment and clinical criteria
We are having a discussion with the coders regarding the new guideline for code assitnment
FY 2017 A.19 code assignment and clinical criteria. The assignment of a diagnosis code is based on the providers diagnostic statement that the condition exists. The providers 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.
From a CDI persepective, we know at times there are inconsistencies in what is written and what is done. We try to clarify the validity of a diagnosis when we do not see any treatment documented, Does this change the accuracy of what is reported if there is not clinical data to support the diagnosis and the coder captures it based on this direction.
In the past I've always been aware of conditions that impact resources and ength of stay - do I need to "unlearn" that?
FY 2017 A.19 code assignment and clinical criteria. The assignment of a diagnosis code is based on the providers diagnostic statement that the condition exists. The providers 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.
From a CDI persepective, we know at times there are inconsistencies in what is written and what is done. We try to clarify the validity of a diagnosis when we do not see any treatment documented, Does this change the accuracy of what is reported if there is not clinical data to support the diagnosis and the coder captures it based on this direction.
In the past I've always been aware of conditions that impact resources and ength of stay - do I need to "unlearn" that?
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Hi Tracy,
My read of this guideline is that it mainly is to clarify that code assignment can not be based off of criteria. Meaning we cannot, for example, tell coders to only code sepsis if the patient meets sepsis-3. If the provider documents sepsis, it should be coded.
This doesn't NOT change the obligation to query if clinical indicators are missing (or other query reasons). If a condition is documented but it does not appear to be clinically supported, we can (and should) still query.
To me this guideline is consistent with what we have already been doing in practice. When a physician documents a particular diagnosis, we have 2 options. Query or Code. We (coding) can not ignore a documented diagnosis just because the diagnosis is not well supported.
Katy
Exactly what Katy says is the accepted translation of this guideline. A Coding Clinic, as well as several articles have been issued on the topic.
Here's a link to one article I found helpful
http://www.medpartners.com/guideline-19-code-assignment-clinical-criteria/
Here's the Coding Clinic
Question:
Please explain the intent of the new ICD-10-CM guideline regarding code assignment and clinical criteria that reads as follows: "The assignment of a diagnosis code is 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." Some people are interpreting this to mean that clinical documentation improvement (CDI) specialists should no longer question diagnostic statements that don't meet clinical criteria. Is this true?
Answer:
Coding must be based on provider documentation. This guideline is not a new concept, although it had not been explicitly included in the official coding guidelines until now. Coding Clinic and the official coding guidelines have always stated that code assignment should be based on provider documentation. As has been repeatedly stated in Coding Clinic over the years, diagnosing a patient's condition is solely the responsibility of the provider. Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis, can "diagnose" the patient. As also stated in Coding Clinic in the past, clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider's clinical judgment, or eliminate the need for provider documentation regarding the clinical significance of a patient's medical condition.
The guideline noted addresses coding, not clinical validation. It is appropriate for facilities to ensure that documentation is complete, accurate, and appropriately reflects the patient's clinical conditions. Although ultimately related to the accuracy of the coding, clinical validation is a separate function from the coding process and clinical skill. The distinction is described in the Centers for Medicare & Medicaid (CMS) definition of clinical validation from the Recovery Audit Contractors Scope of Work document and cited in the AHIMA Practice Brief ("Clinical Validation: The Next Level of CDI") published in the August issue of JAHIMA: "Clinical validation is an additional process that may be performed along with DRG validation. Clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record. Clinical validation is performed by a clinician (RN, CMD, or therapist). Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials."
While physicians may use a particular clinical definition or set of clinical criteria to establish a diagnosis, the code is based on his/her documentation, not on a particular clinical definition or criteria. In other words, regardless of whether a physician uses the new clinical criteria for sepsis, the old criteria, his personal clinical judgment, or something else to decide a patient has sepsis (and document it as such), the code for sepsis is the same-as long as sepsis is documented, regardless of how the diagnosis was arrived at, the code for sepsis can be assigned. Coders should not be disregarding physician documentation and deciding on their own, based on clinical criteria, abnormal test results, etc., whether or not a condition should be coded. For example, if the physician documents sepsis and the coder assigns the code for sepsis, and a clinical validation reviewer later disagrees with the physician's diagnosis, that is a clinical issue, but it is not a coding error. By the same token, coders shouldn't be coding sepsis in the absence of physician documentation because they believe the patient meets sepsis clinical criteria. A facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system.
Hope this helps!
Jeff
Kathleen
As far as asking the physician to provide documentation for their clinical support, I believe that can go either way. We often/usually don't ask for that however.
As far as whether a rule in/out answer is enough to code ... depends on the 'audience'. The new coding guidelines certainly reinforced the long standing convention supporting the coding. However, I really don't see various auditors changing their behaviors either!
Don
Kathleen,
In my take its really specific to the record. For example, If they make a clinically unsupported dx of sepsis which is in the H&P and first PN but then not carried into later documentation. I would query for rule in/out. But if the documentation for respiratory failure (for example) is carried all the way through the record, I would query for clinical indicators/reverse query.
Katy