Clinical Validation vs Reportable Criteria
My opinion is that CC4Q16p147-149 has created some confusion. It states in part, "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". Treatment is given in sepsis cases and therefore meets reportable criteria. Code assignment of any condition should be based on 2 things: 1) how & where it's documented and 2) reportable criteria. The 2019 Guidelines include: "As with all other diagnoses, the codes for psychoactive substance use disorders (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-,F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses)". I welcome others' thoughts.
Comments
There is an excellent article, pg 66, Journal of AHIMA, July-August, 2018, by Tammy Combs, Director of HIM Practice, CDI, that provides insight into this complex topic. One statement: "The assignment of a diagnostic code is based on the provider's diagnostic statement that the condition exists".... 'This instruction means a diagnostic statement cannot be eliminated just because the CDIS or Coding Professional does not feel it is supported by clinical evidence'.
Really too complicated to paraphrase, and I must respect copyright...every CDI team and Coding Team should study this article in depth, IMO.
Paul Evans RHIA CCDS