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With the 2017 ICD-10-CM and PCS coding update on the horizon, we in the healthcare industry have a lot to talk about.

One of the most important and possibly controversial updates affects Section I of the ICD-10-CM Official Guidelines for Coding and Reporting. This new guideline, titled Code assignment and Clinical Criteria,specifically addresses the growing practice of coders and auditors deciding whether to report a code for a documented condition based on the presence or absence of physician-documented clinical indicators. 

You may be a coder, auditor, or in a leadership role at a facility with a policy requiring you to justify coding a diagnosis documented by the attending physician by looking for documentation of the specific published clinical indicators for that condition in the chart. I call these “textbook” clinical indicators, because this practice reminds me of prepping to pass a coding certification exam.

If you hold certain credentials, then you will remember the difference between “textbook coding” and “real-life coding.” There is a definite difference between the two. “Textbook coding” scenarios can always be coded, because the documentation is perfect. “Real-life” scenarios are often murky at best and sometimes need clarification by our physicians.  

In a perfect coding world, all documentation would lend itself to “textbook coding.” However, we live in an imperfect world, and the majority of patients and hospital admissions do not fit into a neat little coding box. In an effort to guide the coding in our facilities back into that neat little coding box, however, and most likely in response to some unfair audits with stiff penalties attached to them, we coding and compliance professionals may have lost our way a bit as of late. Let me explain. 

Where Is Our Respect for Our Doctors?

While we all understand all too well the issue of over-documentation of certain conditions such as sepsis, acute respiratory failure, post-operative respiratory failure, acute kidney injury/failure, and more, this is where I think we may have lost sight of our coding authority. In the wake of so much emphasis on documentation improvement in our move to ICD-10, many of us have come to presume that our physicians are documenting incompletely, if not poorly, most of the time.  You may be thinking, “but Dr. So-and-So gives everyone respiratory failure, even when I’m sure the patient doesn’t have it.”

I too have had those thoughts when reviewing records. But here’s the catch: how many of us coders and auditors have attended medical school? Passed the medical boards? Are legally qualified to examine and diagnose patients? Definitely not me – although I’m pretty sure I have some mad diagnosing skills for my friends and family. Ask yourself this question: have we become such coding experts that we feel we are equal in knowledge to our physicians? That we can decide whether they diagnosed a patient appropriately, according to our coding standards? 

The Caveat

But there’s a problem – a big problem. The first part of the problem is Recovery Auditor (RA) audits. Add to that the verbage in the Conditions of Participation stating that diagnoses documented and “clinically validated” in the medical record by the physician are to be coded. Many of these auditors are reviewing our coded charts and deciding that certain diagnosis codes need to be removed, because the clinical indicators are not documented in the chart to support the physician’s diagnosis of the patient. So because they are RAs, they are allowed to override the physician’s diagnosis, right? Not so fast. Did these auditors examine the patient? Do they have medical degrees? Did they pass the medical boards and are they legally qualified to diagnose patients?

I want to explore for a moment what “clinically validated” actually means. Let me preface this with the fact that I do not know for sure what the Centers for Medicare & Medicaid Services’ (CMS’s) intended meaning was when it defined “clinically validated,” and that’s the problem. Nobody really knows exactly what it means, so it is left to interpretation. The Oxford Dictionary defines the word “clinical” as follows: “(adj.) of or relating to the observation and treatment of actual patients, rather than theoretical or laboratory studies.” 

Merriam-Webster defines the word “validated” as meaning “to support or corroborate on a sound or authoritative basis; to recognize, establish, or illustrate the worthiness or legitimacy of.” Taking these definitions into consideration, there is not a strong case that the term “clinically validated” necessarily means that clinical indicators of each diagnosed condition have to be documented by the physician to qualify for code assignment.

I would venture to say that CMS probably doesn’t officially advocate removing codes for conditions that physicians document because the specific clinical indicators are not present. CMS does, however, continue to contract with RAs that are regularly doing this, blurring the lines of coding authority.

Many of us have decided to interpret “clinically validated” to mean that clinical indicators must be documented to support the physician’s diagnosis. I believe we have done this over a period of time, little by little, and that has brought us to where we are today. Let me ask you to think about this: what about those patients who defy the norm? Consider the patient who comes in with no “textbook” symptoms, yet their physician is sure they have a certain disease or disorder and treats them as such? What about the diabetic patient who is treated for infection without the “textbook” signs and symptoms, because it is best practice to do so and the physician believes they are on their way to the infection? Perhaps we have become legalistic in our coding, in that we are attempting to make the gray areas black and white.

Is this Really a Coding Issue?

After extensive research, I have not found any directives in official coding guidelines, Coding Clinics, or on the CMS website that extend the authority to us, as coders and auditors, to decide whether a legitimately documented physician diagnosis is clinically substantiated enough for code assignment. Earlier in this article I mentioned respect for our doctors. While we all have found ourselves in situations in which a physician has documented a diagnosis with little to no substantive documentation to support the condition, I believe we do have to defer to our doctors’ expert medical knowledge and authority.

As coding and auditing professionals, we are directed to follow the ICD-10-CM Official Guidelines for Coding and Reporting. Those guidelines tell us that the term “provider” means “…the physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis.” Our medical staff bylaws in our hospitals stipulate that the attending physician is responsible for the final diagnoses of patients, in keeping with the Joint Commission and other regulatory authorities.

How, then, can we as coders and auditors have the authority to decide what diagnoses are coded and what diagnoses are not coded based on the presence or absence of clinical indicators?

The Solution

What’s the solution? Facilities are stuck between a rock and a hard place. We must follow the coding guidelines, yet we are being penalized by auditors taking away codes (and money) due to lack of clinical indicators documented in our charts. There isn’t a clear solution yet. No matter where you stand on the issue, however, the cooperating parties have spoken with the addition of this guideline for 2017. They have told us, as coding professionals, that we do not have the authority to use clinical indicators for code assignment. 

I do believe this guideline addition will affect everyone – coders, auditors, compliance staff, clinical documentation improvement (CDI), leadership, and yes, even CMS and RAs and other contractors. Due to this guideline addition, it looks like everyone, even CMS, has some work to do to correct this problem. Perhaps the cooperating parties added this guideline to rein in a coding and auditing practice that is getting out of control.

Perhaps CMS will discontinue contracts with RAs that practice this kind of auditing, since CMS maintains that they too follow the official coding guidelines. Maybe CMS will better define “clinically validated.” We can communicate with our physicians (especially Dr. So-and-So) and CDI staff and work together to improve the never-ending documentation issues. We will all be watching and waiting to see how this all shakes out.

One thing I know is what the solution is not: placing responsibility on coders and auditors to justify physician-documented diagnoses for code assignment.


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