ICD-10-CM/PCS Lessons Learned Regarding the Official Guidelines and Coding Clinic

The actual go-live of ICD-10-CM/PCS was generally smooth, with no major problems. 

For health information management (HIM) coding and clinical documentation improvement/integrity (CDI) professionals, the use of and adherence to the ICD-10-CM/PCS Official Guidelines for Coding and Reporting is a must.

In addition, the American Hospital Association (AHA) ICD-10-CM/PCS Coding Clinic is essential. These two publications are indispensable resources for all involved in clinical coding, and those in CDI. As part of the implementation of ICD-10 in October 2015, we all heard and read much about the “Official Guidelines” and AHA Coding Clinic, as they were and are still foundational to quality clinical data. So, what have been some of the other lessons learned since implementation?

I reflect first upon the two-plus years prior to 2015, and the depth of education on the Official Guidelines that was delivered and emphasized repeatedly. Providing this education across the United States to more than 2,000 coding and CDI professionals was extremely enlightening on a personal level. I recall times when attendees at ICD-10 educational programs had not ever read the Official Guidelines before that specific program. Somewhat shocked as I was, when an attendee would ask me where to locate the Official Guidelines, it presented an opportunity to drive home the importance of and need for every coding professional in every healthcare setting to really understand them.

Likewise, I found during ICD-10 implementation readiness processes that the AHA Coding Clinic was often not available to coding and CDI professionals. In addition, there was a misunderstanding about the setting for which Coding Clinic applies. That confusion often stemmed from the fact that the AHA publishes Coding Clinic, and non-hospital setting staff were confused as to whether the guidance applied to them or not. Of course, there was guidance from Coding Clinic that would only apply to the hospital setting, but there were other times when it would apply to all settings. Since the implementation of ICD-10, the availability of the Coding Clinic, and the knowledge that it is for all healthcare settings, have improved.

Also, I believe that since October 2015, we’ve had an upsurge of attention regarding the Official Guidelines and AHA Coding Clinic, overall. The actual go-live of ICD-10-CM/PCS was generally smooth, with no major problems.

View PDF of Coding Guidelines here.

Contained within the Official Guidelines are the “conventions,” of which there are 19. Two conventions, in particular, have been discussed over and over again, over the past few years: guideline conventions Nos. 12 and 15.

In the 2020 version of the guidelines, the following language is from conventions 12 and 15, for your reference:

#12 Excludes Notes. The ICD-10-CM has two types of excludes notes. Each type of note has a different definition for use, but they are all similar in that they indicate that codes excluded from each other are independent of each other.

1. Excludes1 A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider. For example, code F45.8, Other somatoform disorders, has an Excludes1 note for “sleep-related teeth grinding (G47.63),” because “teeth grinding” is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding. However, psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and sleep-related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together. b. Excludes2 A type 2 Excludes note represents “Not included here.” An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

#15 “With.” The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index (either under the main term or subterm), or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated, or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”).

For conditions not specifically linked by these relational terms in the classification, or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related.

The word “with” in the Alphabetic Index is sequenced immediately following the main term or subterm, not in alphabetical order.

View PDF of 2020 Coding Guidelines here

We continue to see and hear issues about these two conventions; however, we’ve also found that having an open dialogue about them is key to a positive outcome.

Since October 2015, some lessons learned involving the Official Guidelines include but are not limited to the following:

• Reading the Official Guidelines carefully and repeatedly in order to gain a greater understanding of the classification system is vital;
• Utilizing and increasing the referencing of the Official Guidelines, even in the non-hospital settings, can help set the proper tone;
• More coding and CDI professionals have gained a higher understanding of the Official Guidelines conventions, instructions, and meaning;
• Guidelines change and have become more detailed and refined, so each year we are paying more attention to the changes;
• Clinical documentation linkage to clinical coding continues to be a key issue for which the Official Guidelines are providing insight and direction; and
• The Official Guidelines are aiding in achieving and maintaining compliance.

The AHA Coding Clinic is an official coding resource, and as such, it is a necessity for HIM, coding, and CDI professionals in all healthcare settings. As with anything new, there are always going to be questions, like with ICD-10-CM/PCS. The AHA Coding Clinic is the clearinghouse for all ICD-10-CM/PCS questions.  

One of the great benefits of subscribing to the AHA Coding Clinic is that questions can be submitted online and are answered without a fee. Through the past four years, we received quarterly updates through the AHA Coding Clinic, which have addressed many ICD-10-CM (diagnosis) and ICD-10-PCS (Procedure Coding System) issues. To quote a colleague, “I do think that Coding Clinic has done an excellent job in addressing the most pressing coding quandaries thus far.”

Lessons learned since October 2015 involving AHA Coding Clinic include but are not limited to the following:

• Reading the guidance carefully is pivotal;
• Coding Clinic guidance can result in changes to one’s coding practices and even documentation improvement activities, so be prepared to change, adapt, and adopt;
• Greater awareness of inpatient procedure coding and the clinical details of such (i.e., anatomy and physiology) has increased;
• Having the AHA Coding Clinic subscription in place even for the non-hospital setting is more common;
• More ICD-10-CM/PCS questions are being submitted due to an increased awareness of the process;
• Quarterly publications need to be kept up with; thus, reading and discussing each Coding Clinic has great value, which more professionals are now mindful of; and
• Coding audits continue to offer value, and reviewers (auditors) utilize and reference the AHA Coding Clinic guidance.

With the adoption of ICD-10-CM/PCS, we’ve all experienced major changes, and sometimes even frustration and confusion. But using the Official Guidelines and AHA Coding Clinic, we’ve been able to achieve a significant increase in understanding of the coding classification system.

This has a positive impact on overall coding quality and integrity. It’s hard to believe that we’re now into our fifth year of ICD-10-CM/PCS; oh what a time we’ve had! Keep up the hard work achieving quality coded data, and use your Official Guidelines and AHA Coding Clinic on a regular basis!

Programming Note:

Listen today as Gloryanne Bryant report this story live during Talk Ten Tuesday, 10-10:30 a.m. EST.