General Question for the Week of May 1, 2017

Question:

One of our commercial insurers has denied our claims based on a “lack of clinical indicators.” We are assigning diagnostic codes based on the physician’s diagnostic statements. Should we be doing something else?

Answer:

For fiscal year (FY) 2017, the Centers for Medicare & Medicaid Services (CMS) introduced a new ICD-10 coding guideline. Guideline 19—Code Assignment and Clinical Criteria—in section I.A. states the following: “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.”

As hospital billing and coding professionals know, third-party reviewers and payers often ignore current guidelines so they can reduce payment. Coders must continue to work with providers to make their documentation bulletproof. In many cases, it may not be enough to simply document a specific diagnosis for a patient. Instead, the physician must be able to prove—beyond a shadow of a doubt—that the patient has a serious and life-threatening illness.