Coding and Clinical Criteria: The Value of an Escalation Policy

As coders, we often face dilemmas without benefit of clear guidance, creating the feeling of being pulled in different directions. In today’s audit environment, coders need practical solutions to succeed in a setting of conflicting expectations. This article focuses on coding and clinical criteria dilemmas, and the value of having a facility policy for coding in these situations.

Codes should tell the story of a patient’s encounter. Yet how do we make sure we’re telling the true story – striking a balance between overstating and understating? In a recent training session, several polling questions were presented to illustrate various dilemmas, including the following:

Here is one example of a common scenario:

Documentation includes a laboratory finding of serum sodium value of 120 mmol/L. Normal range is 135-145 mmol/L. The attending physician documents hypernatremia in the final diagnostic statement, but there is no mention of the word “hyponatremia” in the record. What should be done?

  1. Code hypernatremia
  2. Code hyponatremia
  3. Send a query to the attending physician regarding hypernatremia
  4. Code either hypernatremia or hyponatremia and report the case to designated person at your facility
  5. Other__________

Most respondents chose C: send a query, including the lab values. For answer D, you would need an escalation process in place for reporting, and many organizations lack a strategy for doing so. 

Here are three other dilemmas to consider:

  • Diagnosis is stated only on a query response. Is the query part of the legal medical record? Clinical documentation improvement specialist (CDIS) or coder query? For some facilities, coder queries are a part of the legal medical record, but CDI queries are not. Policies vary by facility.
  • Diagnosis is stated only in the ED record. Is there a facility policy for coding? Would this hold up under audit scrutiny? Is the decision left to coder discretion? Recommended policy: If documented only in the ED record and not mentioned again, then send a query. Without clear direction, CDI and coding may handle the situation differently from one case to another.
  • Though CDI and coding are complementary, the boundaries are not entirely clear. The two professions often approach cases from different perspectives based on department priorities. Joint training would be beneficial to promote understanding of both perspectives and knowledge of coding rules.

Of all the numerous challenges involved with coding, one of the most common dilemmas occurs when clinical criteria do not appear to match a provider’s documented diagnosis. When the provider documents a condition and there are weak or missing clinical indicators, this will likely raise a red flag to external auditors. Coders need an internal escalation process to provide proper guidance.

Evolution of Coding Responsibilities and Guidance

When it comes to establishing policy, historical perspective lends insight. Since the 1980s, we’ve gone through multiple iterations of federal auditing bodies along with expectations to properly assign codes that impact reimbursement – and now, quality indicators. With that evolution came the need for coders to understand how to interpret and query regarding diagnoses and clinical indicators. Fast forward to 2017, and we’re now reestablishing the boundaries to define coder responsibilities.

As ICD-10 matures, coding guidelines will continue to evolve accordingly. For example, three sentences were added to the ICD-10-CM guidelines in October 2016, formally alleviating the coder’s burden of validating diagnoses against clinical criteria and questioning physicians’ diagnostic statements: 

2017 ICD-10-CM Guideline I.A.19—Code assignment and Clinical Criteria:

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. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

On the heels of that update, Page 147 of the Coding Clinic published during the fourth quarter of 2016 expanded the guidance to further explain implications. A question was posed asking if the new guideline means that CDISs should no longer query on diagnostic statements that don’t meet clinical criteria. Coding Clinic’s response included these points:

  • Coding and clinical validation are separate functions. Clinical validation may be performed by a clinician, including RNs.
  • Clinical definitions change rapidly, and applying them is subjective, based on an unknown baseline of the patient and changes to that baseline. Physicians use their knowledge of the patient and judgment to arrive at a diagnosis.
  • The final statement points out that if the physician documents sepsis, the coder assigns a sepsis code, and later a reviewer disagrees with the physician’s diagnosis because of lack of clinical criteria, that is a clinical issue, not a coding error.

The question applies to coding as well as CDI professionals. Though coding and clinical validation are separate functions, we all work for “the facility” and share responsibility to ensure that documentation is complete, accurate, and appropriately reflective of patient conditions. Coders are not directly responsible for validating the clinical criteria to support the provider’s diagnostic statements, but they do need to have an avenue in which to forward concerns to the appropriate clinical staff when documentation does not seem to match the clinical picture.

Establishing an Escalation Policy

Coders and CDI professionals see documentation firsthand every day and are experts at identifying discrepancies, conflicting statements, and documentation that is not aligned with the patient’s clinical picture. When repeated querying and provider education have not worked to improve the quality of your facility’s documentation, a policy must be in place for front-line users of information to report their observations. 

An escalation process may involve a physician advisor, chief medical officer, or other administrative personnel who can help address unanswered queries and unsatisfactory responses. Or, you may choose to create a multidisciplinary team, involving health information management (HIM), CDI, compliance, quality, auditors, legal staff, and physicians. Coders and CDI staff can forward cases to the designated person or team for guidance when clinical support for a documented diagnosis is questionable.

With the shift to value-based care, clinical guidance is necessary to mitigate risks as they pertain to audits, compliance, quality of care, and reimbursement. Expressing your concerns through a defined escalation process can make a difference in your facility’s reimbursement and quality report cards in the long run. In doing so, you can play a pivotal role in preventing risk while ensuring compliance, proper payment, and accurate reflection of high-quality care.

Best Practices

Here are seven best practices to help ensure appropriate documentation supported by clinical indicators:

  • Implement an effective escalation policy.
  • Identify common and risky targets, looking for patterns of denials, U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) targets, Recovery Audit Contractor (RAC) scope of work, and audit tricks.
  • Advance pre-bill efforts to identify and correct problems.
  • Create or expand a CDI program to ensure concurrent intervention.
  • Establish a well-defined query process.
  • Solicit feedback from providers, CDISs, and coders.
  • Offer provider education, keeping in mind the importance of quality data:
    • Response to queries, part of legal medical record
    • Awareness of clinical validation billing denials
    • Documentation: complete, accurate, timely


The American Health Information Management Association (AHIMA) provides a variety of resources to help design, develop, and support the process of ensuring quality documentation for patient care, coded data quality, and reimbursement.

AHIMA Toolkits are available online here:

  • Clinical Documentation Improvement (CDI) Toolkit
  • Government Audit
  • Query

AHIMA Standards of Ethical Coding:

An addendum* to the “Guidelines for Achieving a Compliant Query Practice” (February 2013) with helpful examples of escalation policies: 

*Updated in 2016, available to AHIMA members only:

Print Friendly, PDF & Email

Linda Schwab-Messmer, RHIT, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer

Linda Schwab, RHIT, CC, is the manager of coding operations for The Coding Group, a Division of IRM. She has 25 years of HIM/Coding experience. Her past work includes serving as assistant director HIM, coding manager, HIM coordinator for Colorado HHA, DRG and facility coding auditor and educator.

Related Stories

You’re Giving Me a Heart Attack

You’re Giving Me a Heart Attack

Today I would like to call your attention to Type 2 myocardial infarction (MI), A21.A1, versus demand ischemia, I24.89. I frequently see denials associated with

Print Friendly, PDF & Email
Read More
Two Things I Learned at AHIMA’s 2023 Convention

Two Things I Learned at AHIMA’s 2023 Convention

Just in case you hadn’t heard or read it somewhere else, it was announced at the American Health Information Management Association (AHIMA) House of Delegates

Print Friendly, PDF & Email
Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Revolutionize Case Management and Revenue Cycle Team Collaboration to Improve Patient and Financial Outcomes

Revolutionize Case Management and Revenue Cycle Team Collaboration to Improve Patient and Financial Outcomes

Unlock the keys to bridging the clinical-finance disconnect by transforming your approach to revenue cycle collaboration for superior patient care and financial prosperity!

Join Dr. Ronald Hirsch as he delves into the pivotal connection between case management, utilization review, and hospital revenue cycles, unveiling strategies to enhance communication and align goals effectively. Discover how to overcome hidden challenges hindering seamless collaboration and gain insights imperative for success

Print Friendly, PDF & Email
December 7, 2023
Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

The CMS Two-Midnight Rule and short-stay audits are here to stay, impacting inpatient and outpatient admissions, ASC procedures, and Medicare Parts C & D. New for 2024, the Two-Midnight Rule applies to Medicare Advantage patients, requiring differentiation between Medicare plans affecting Case Managers, Utilization Review, and operational processes and knowledge of a vital distinction between these patients that influences post-discharge medical reviews and compliance risk. Join Michael G. Calahan for a comprehensive webcast covering federal laws for all admission processes. Gain the knowledge needed to navigate audits effectively and optimize patient access points, personnel, and compliance strategies. Learn Two-Midnight Rule essentials, Medicare Advantage implications, and compliance best practices. Discover operational insights for short-stay admissions, outpatient observation, and the ever-changing Inpatient-Only Listing.

Print Friendly, PDF & Email
September 19, 2023
Unlocking Clinical Documentation Excellence: Empowering CDISs & Coders

Unlocking Clinical Documentation Excellence: How to Engage the Provider

Uncover effective techniques to foster provider understanding of CDI, empower CDISs and coders to customize their queries for enhanced effectiveness, and learn to engage adult learners, leveraging their experiences for superior learning outcomes. Elevate your CDI expertise, leading to fewer coding errors, reduced claim denials, and minimized audit issues.

Print Friendly, PDF & Email
December 14, 2023
Coding for Spinal Procedures: A 2-Part Webcast Series

Coding for Spinal Procedures: A 2-Part Webcast Series

This exclusive ICD10monitor webcast series will help you acquire the critical knowledge you need to completely and accurately assign ICD-10-PCS and CPT® codes for spinal fusion and other common spinal procedures.

Print Friendly, PDF & Email
October 26, 2023
Inpatient Spinal Fusions: Mastering Anatomy, Coding and Documentation

Inpatient Spinal Fusions: Mastering Anatomy, Coding and Documentation

During this exclusive ICD10monitor webcast, inpatient coders will gain a profound understanding of prevalent spinal procedures. They’ll delve into the intricate anatomy, grasp the purpose and method behind these procedures, uncover essential elements within physician documentation, and receive expert guidance, step by step, on constructing accurate ICD-10-PCS codes. It’s the key to enhancing their expertise and ensuring coding precision.

Print Friendly, PDF & Email
October 26, 2023

Trending News