New Coding Clinic Q4 2017 and Institutional Defintions

Just curious if anyone's seen the new 4Q Coding Clinic regarding Institutional Definitions...thoughts?  While the definitions an be helpful in setting educational standards, generating queries, and supporting appeals, has the Coding Clinic idea that they cannot be used to guide coding practices basically set us up for confrontations (aka "clinical validation queries") with physicians and at risk of "overcoding' for audits?


  • I am not sure I understand your question? I am reading the guidance to state one should use and develop clinical criteria as one way to ensure a logical and consistent approach for CDI professionals.  I do not think Coding Clinic is setting us up for confrontations or placing us at risk for over coding audits.  The guidance is stating we may, and should, review documentation to 'validate' diagnoses: but, at the end of the day,  the Attending is responsible for establishing a diagnosis, and no site may elect to delete a code documented.    The confrontation I am most concerned with is 3rd party auditors that determine that certain diagnoses 'do not meet their criteria', but do not share with the CDI profession the precise criteria they employ; I think we have all experienced denials for certain conditions that MET medical standards and definitions (N17.9 - acute kidney injury), as an example, in which KDIGO criteria may be exceeded, and is clearly documented, yet, denied by a 3rd party. 

  • Here is the Entry:


    Coding Clinic, Fourth Quarter 2016, page 149, states “A facility may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis”. Would it be appropriate for facilities to develop a policy to omit a diagnosis code based on the provider’s documentation not meeting established criteria?

    Answer: No. It is not appropriate to develop internal policies to omit codes automatically when the documentation does not meet a particular clinical definition or diagnostic criteria. Facilities may review documentation to clinically validate diagnoses and develop policies for querying the provider for clarification to confirm a diagnosis that may not meet particular criteria.

    Facilities should also work with their medical staff to ensure conditions are appropriately diagnosed and documented. If after querying, the attending physician affirms that a patient has a particular condition in spite of certain clinical parameters not being met, the facility should request the physician document the clinical rationale and be prepared to defend the condition if challenged in an audit. The facility should assign the appropriate code(s) for the conditions documented. 

    The part of the clinic the that really gets me is is the following:  

    “If after querying, the attending physician affirms that a patient has a particular condition in spite of certain clinical parameters not being met, the facility should request the physician document the clinical rationale and be prepared to defend the condition if challenged in an audit.” 

    This is a somewhat of a paradigm shift.  In the past we sort of excused ourselves from the clinical validation discussion by citing the official AHIMA query guidelines as well as codes of ethics which prevented us from “questioning a physician”. 

    4th Quarter 2017 indicates that for cases where there is an atypical presentation and the standard best practice indicators and treatments do not appear to be at play, we should in fact ask the physician to “document the clinical rationale”.   This supports the idea of clinical validation with regards to queries.  In the end, we still really aren’t “questioning the doctors judgement”, but rather this new guidance gives us a wider range of liberties in terms of reminding the physician to improve the documentation for atypical cases or to amend the documentation if a condition was ruled out. 

    Fourth quarter 2016 really addresses the CMO’s responsibility in defining a particular facility definition for their diagnostics.  A good example of this would be Trey La Charites’s facilities position that they do not accept SOFA criteria as a standalone definition of sepsis.  Coding clinic is saying that such facility definitions are acceptable.  To me however, that has little to do with the practice of coding.  It does however impact CDI as it can influence when a query is placed or withheld, depending on the facility definition. 

    The part of 4th Q 2016 that really bothers me is the “or a payer” in this sentence. 

    “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”.    “Or a payer”  essentially validates the games the commercial payers play that I call “hide the criteria”, leaving doctors and case managers to essentially guess or use a magic 8 ball when attempting to ascertain medical necessity based coverage data.     Paul hit the nail on the head with denials for AKI even though the patient clearly met the accepted best

  • Full entry below.


    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 148 Coding Clinic Fourth Quarter 2016

    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?


    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 Coding Clinic Fourth Quarter 2016 149

    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.

  • And Just for Fun:

    The part that I often reference when ranting about the Fiscal Intermediaries (which are essentially the same regions and companies as the modern day recovery auditors incidentally) is in bold. 


    Clarification, coding disputes with payers

    Browse Issue

    Clarification, coding disputes with payers

    Coding Clinic, Third Quarter 2000 Page: 13 to 14

    Effective with discharges: September 1, 2000   




    While Coding Clinic for ICD-9-CM  traditionally has not addressed coding for reimbursement, the Central Office on ICD-9-CM and the Cooperating Parties have recently received many questions regarding discrepancies between coding guidelines or advice published in Coding Clinic and payer coding policies. Coding Clinic's goal is to provide advice according to the most accurate and correct coding consistent with ICD-9-CM principles.


    There are a variety of payment policies that may impact on coding.  Many of those payment policies may contradict each other or may be inconsistent with ICD-9-CM rules/conventions. Therefore, it is not possible to write coding guidelines that are consistent with all existing payor guidelines.


    The following advice is provided to help providers resolve coding disputes with payers:


      First, determine whether it is really a coding dispute and not a coverage issue.  For example, a payer may deny codes V72.5 and V72.6, for encounters for radiology and laboratory examinations.  These codes are to be used only for routine examinations without signs or symptoms.  Many payers do not provide coverage for routine tests.  So, such denials are not due to incorrect coding, but rather relate to non-coverage of routine tests, e.g. annual physical exams, screening tests without signs or symptoms.  Therefore, always contact the payer for clarification if the reason for the denial is unclear.


      If a payer really does have a policy that clearly conflicts with official coding rules or guidelines, every effort should be made to resolve the issue with the payer.  Provide applicable coding rule/guideline to payer.  For Medicare claims, contact the fiscal intermediary (FI) or carrier contractor for clarification. If you are not satisfied with the answer you receive, follow up with the HCFA Regional Office.  The FI or carrier should be able to provide you with information as to which Regional Office has jurisdiction over your area.


      If the payer refuses to change its policy, obtain the payer requirements in writing. If the payer refuses to provide their policy in writing, document all discussions with the payer, including dates and the names of individuals involved in the discussion.   Confirm the existence of the policy with the payer's supervisory personnel.


      Keep a permanent file of the documentation obtained regarding payer coding policies.  It may be come in handy in the event of an audit.


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