New clinical criteria definitions in 2017 Official Guidelines up the ante for coders

by Laura Legg, RHIT, CCS, CDIP, and AHIMA-approved ICD-10-CM/PCS trainer

The new guideline for code assignment and clinical criteria in the 2017 ICD-10-CM Official Guidelines for Coding and Reporting does not mean clinical documentation improvement is going away; instead it just upped the ante for continued improvement.

Up the ante means to increase the costs, risks, or considerations involved in taking an action or reaching a conclusion. With the new coding guideline for clinical validation that went into effect October 1, the stakes remain high for the diagnoses documented by the physician to be clearly and consistently demonstrated in the clinical documentation.

It is not that the information was not there before, but now the issue is finally getting attention. When clinical documentation is absent, coders are instructed to query the provider for clarification that the condition was present. But what are we to do if the clinical indicators are not clearly documented? For HIM professionals who deal with payer denials, this has been a haunting issue for a very long time.

The ICD-10-CM Official Guidelines for Coding and Reporting are the foundation from which coders assign codes. Coders need to review the new guidelines in detail to understand the changes and implications for their facilities.

The Centers for Disease Control and Prevention published these new guidelines which can be read in their entirety here: www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf.

Taking a closer look

The coding guideline for section A.19 (code assignment and clinical criteria) has been labeled as controversial and, at this point, we have more questions than answers. Denials issued by payers due to the absence, or perceived absence, of clinical indicators by which the payer lowers the DRG is now being called DRG downgrading and it’s getting attention.

The code assignment and clinical criteria states:

Physicians and other providers document a patient’s condition based on past experience and what the clinician learned in medical school, which often differs from clinician to clinician. When you put a patient in front of a group of clinicians you will most likely get differing documentation. So how do we fix that?

The diagnosis of sepsis is a good example. There does not appear to be a universally accepted and consistently applied definition for the condition of sepsis.

In a patient record with the principal diagnosis code of sepsis, followed by the code for the localized infection, pneumonia, a payer denial could occur.

Payer denials often deny the sepsis diagnosis code stating that "the diagnosis of sepsis was not supported by the clinical evidence. Therefore, as a result of this review, the diagnosis code A41.9 [sepsis, unspecified organism] has been removed and the principal diagnosis re-sequenced to code J18.9 [pneumonia, unspecified organism] for pneumonia and to the lower paying DRG 193." This is now being referred to as a DRG downgrade. DRG downgrades can occur for different reasons including both DRG coding changes and clinical validation downgrades.

What is a coder to do?

What is a coder to do when a physician documents a diagnosis that may not be supported by the clinical circumstances reflected in the patient’s chart? Facilities and coding teams should develop guidance and be sure they fully understand the content and the impact of this coding guideline to coding practices.

Remember the section that reads: "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."

This represents a catch-22. If the diagnosis is not clinically validated, both recovery auditors (RA), as well as commercial insurance auditors, are going to deny the claim. On the other hand, if coders or the facility decide not to report the diagnosis, they are in violation of the coding guidelines, which is also a major problem.

AHIMA’s 2016 Clinical Documentation Toolkit offers this advice:

The toolkit is available here: http://bok.ahima.org/PdfView?oid=301829.

Increasing clinical documentation

As the healthcare industry experiences an increased number of external audits, both federal and private, the need to up the ante on clinical documentation has become essential. The answer is not to let this guidance prompt lazy documentation, which has far reaching consequences, but to use it as a catalyst for improvement.

The goal of any clinical documentation improvement (CDI) program is to ensure a complete and accurate patient record, and this cannot be done without the presence of documentation supporting the clinical indicators and clear and consistent documentation regarding the condition. The provider’s documentation of their full thought process will accomplish this. If medical staff can come together and agree upon a definition for a certain condition, they can begin the process of being consistent with how the description is presented in the patient record.

CDI specialists and coders should not use the new guideline as an excuse not to query. Coders are not clinicians and, therefore, should not be expected to evaluate clinical criteria. Coding and CDI were separate functions, but, as audits from outside organizations expand, there is more emphasis on correct coding, DRG assignment, and the use of clinical criteria to support the reported codes, which means these entities need to work together.

The American Hospital Association’s Coding Clinic for ICD-10 instructs coders not to use background clinical information contained in their responses for code assignment. This information is only provided so the coders can make a judgment to query where there is incomplete documentation. Coders and CDI staff should review all chart documentation and data, and query when necessary to clarify inconsistencies in physician documentation.

Query the provider to support their diagnostic and procedural documentation by making a specific reference to the clinical basis of the diagnosis, and also by noting the absence of specific expected criteria such as radiographic findings, lab values, or patient manifestations.

External auditors in turn need to be following the same rules and coding guidelines as we do. Reviewers for facilities plagued by copious denials are finding auditors making up their own rules, using obsolete or outdated criteria, and clearly not understanding basic terminology used in the 2017 IPPS final rule.

DRG downgrading may be illegal, and some states intend to find out using state level legislation. Downgrading is, at the very least, disregarding the physician’s clinical judgment. We can’t forget who has eyes on the patient. Coders and CDI specialists should take documentation one step further and ask physicians to document their thought processes, the clinical indicators they are seeing, and their rationale for diagnosis determination.

Remember, coding is not based on clinical criteria. Coders cannot disregard physician documentation based on clinical indicators in the patient record, so, we will always need to ensure documentation is complete, accurate, and reflective of the patient’s clinical condition.

Editor’s Note:

Laura Legg, RHIT, CCS, CDIP, is an AHIMA-approved ICD-10-CM/PCS trainer, and director of HIM optimization at Healthcare Resource Group in Spokane Valley, Washington. For questions, please contact editor Amanda Tyler at [email protected]. Opinions expressed are that of the author and do not represent HCPro or ACDIS.

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