The Coder-Physician Link: Essential to Patient Care

So here is a different take on how important it is for coders and physicians to have a link with one another, and to respect the professionalism inherent in each field.

The 2017 fiscal year ICD-10-CM Official Guidelines for Coding and Reporting recently produced a new guideline (I.A.19) that had everybody talking. It stated that “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.”  

This statement seems to indicate that no one should believe that clinical criteria do not matter, but rather that coders and clinical documentation improvement (CDI) specialists cannot unilaterally decide when a condition exists based on whether they feel certain criteria are present.

This instruction is all well and good, but understandably, I think it creates a bit of angst for those of us in the physician advisory, coding, and CDI fields who not only have a passion for our contribution to the revenue cycle, but also understand well that some physicians overzealously document. Perhaps they do so in a well-intentioned way, but it still represents an inaccurate response to previous education. 

A good example has been sepsis documentation. There has been a lot of attention paid to this topic because of the changing criteria of late. Many physicians are still using SIRS criteria. If these are applied concretely without any consideration of context, nearly any hospitalized patient can be interpreted as being septic – and of course, this is not the case.

So where does this leave worried coders, CDI specialists, and physician advisors?

The 2016 fourth-quarter edition of the American Hospital Association’s Coding Clinic provided guidance that essentially restated that coding must be based on provider documentation, noting that this is not a new concept (although it had not been explicitly included in official coding guidelines before). 

The point was made that the guideline addresses coding and not clinical validation. Although related to the accuracy of coding, clinical validation is a separate function. This distinction has been described by the Centers for Medicare & Medicaid Services (CMS) in the Recovery Audit Contractor (RAC) scope of work documentation and also in American Health Information Management Association (AHIMA) practice briefs. 

Essentially, clinical validation is an additional process that may be performed along with DRG validation. Clinical validation involves a clinical review of the case to see whether the patient truly possesses the conditions documented in the medical record. Clinical validation is performed by a clinician (RN, therapist, M.D., etc.) and not a coder.

So, if a physician documents a condition and a coder assigns the code for that condition, and a clinical validation reviewer later disagrees with the physician’s diagnosis, that is a clinical issue, but it is not a coding error. Likewise, coders should not be coding conditions in the absence of physician documentation because they believe the patient meets some set of clinical criteria.

All of this further emphasizes the vital link between the clinical side of medicine and the coding/revenue integrity side. The query process is more important than ever to help ensure the production of good documentation and correct coding. With the daily interactions that need to occur with physicians related to their documentation, it is clear that all coding departments should have physician champions or physician advisors to help develop and strengthen the critical link between coders and physicians. It may also be necessary for facilities to develop guidelines pertaining to documentation requirements associated with denial-prone diagnoses.