Assigning Other Diagnoses, section III Coding Guidelines

There are some differing opinions in our organization regarding to the Coding Guidelines.  Section III. Reporting Additional Diagnoses state:

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

There is one argument that if a diagnosis does not meet any of the above criteria, it should not be coded - even if documented.

On the other hand, I.A.19 states, "The assignment of a diagnosis code is based on the provider's diagnostic statement that a 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.

So, the discussion is that if a physician documents a condition - even if it doesn't meet the definition for "other diagnoses" it should be coded...

The other side is, it should not be coded if it doesn't meet the definition for "other diagnoses".

Just wanted some outside thoughts on this.


Thank you!



Comments

  • Hi

    My take is that guideline 1.A.19 is addressing when a physician documents a condition for which there may be issues about the presence of clinical indicators to support the diagnosis.  For example, AKI documented by physician but clinical indicators in record do not support the documentation of AKI.   CDI/Coding may disagree with the physician’s diagnosis of AKI and can query, as necessary.  However, CDI/coding cannot make the decision to not code the AKI because it doesn’t meet clinical indicator criteria.  If provider documents the condition, it is coded. 

    As a separate issue, the AKI (regardless of whether clinical indicators are met) would also have to be assessed for reporting as a secondary diagnosis based on the “Other diagnoses” requirements included in the coding guidelines.  If the AKI doesn’t meet any of the guidelines for affecting patient care (clinical eval, tx , dx, extended LOS, or  increased monitoring), it should not be coded. 

    Looking forward to hearing other opinions. 

    Maggie

     

  • Agree with Maggie.

    Does the original poster have any examples of diagnoses that are in question?

    Jeff

  • jwmorris1 said:

    Agree with Maggie.

    Does the original poster have any examples of diagnoses that are in question?

    Jeff


    So, the most recent example was the MD was documenting acute blood loss anemia in an OB patient after delivery.  No labs were drawn.  No treatment.  No evaluation.  No extended LOS.  Coder A states we should code it because the doc documented it.  Coder B (and myself) say, it doesn't meet the definition of a "other diagnosis" and the code should not be reported.
  • Hi

    My take is that guideline 1.A.19 is addressing when a physician documents a condition for which there may be issues about the presence of clinical indicators to support the diagnosis.  For example, AKI documented by physician but clinical indicators in record do not support the documentation of AKI.   CDI/Coding may disagree with the physician’s diagnosis of AKI and can query, as necessary.  However, CDI/coding cannot make the decision to not code the AKI because it doesn’t meet clinical indicator criteria.  If provider documents the condition, it is coded. 

    As a separate issue, the AKI (regardless of whether clinical indicators are met) would also have to be assessed for reporting as a secondary diagnosis based on the “Other diagnoses” requirements included in the coding guidelines.  If the AKI doesn’t meet any of the guidelines for affecting patient care (clinical eval, tx , dx, extended LOS, or  increased monitoring), it should not be coded. 

    Looking forward to hearing other opinions. 

    Maggie

     


    This question really isn't in regards to clinical criteria.  We have a strong process with that in terms of clinical validation queries etc.  Just meeting the criteria to quality as an "other diagnosis".
  • Doesn't get reported if it doesn't meet the definition is my stance. Guideline 1.A.19 is more for clinical validity where the condition was monitored, evaluated and possibly treated...just doesn't exactly meet evidenced based guidelines. Interested to hear others views.

    Jeff

  • jwmorris1 said:

    Doesn't get reported if it doesn't meet the definition is my stance. Guideline 1.A.19 is more for clinical validity where the condition was monitored, evaluated and possibly treated...just doesn't exactly meet evidenced based guidelines. Interested to hear others views.

    Jeff


    Thanks Jeff.  That is my view as well. 
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