When the new coding guideline for clinical validation went into effect October 1, 2016, the stakes were raised higher for the diagnoses documented by the physician to be clearly and consistently demonstrated in the clinical documentation.

New Coding Guideline 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.

The ICD-10-CM Official Coding Guidelines are the foundation from which coders assign diagnosis codes and the CDC published the new ICD-10-CM Coding Guidelines for discharges effective October 1, 2016.  Among those guidelines was Coding Guideline 19, which has been labeled as controversial and at this point there are more questions than answers. Also denials issued by payers due to the absence or perceived absence of clinical indicators by which the payer lowers the DRG is now being called “DRG downgrading.”

How Coders Can Navigate the New Guidelines:

When clinical documentation is absent, coders are instructed to query the provider for clarification that the condition was present.  But what are we to do if the clinical indicators are not clearly documented? For HIM professionals who deal with payer denials, this feels like being dealt a losing hand.

What is a coder to do when a physician documents a diagnosis that may not be supported by the clinical circumstances reflected in the patient’s chart?  

Remember the section that reads: “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.”  This represents a catch-22.  If the diagnosis is not clinically validated, both Recovery Auditors as well as commercial insurance auditors are going to deny the claim.  On the other hand, if coders or the facility decides not to report the diagnosis, they are in violation of the coding guidelines, which is also a major problem.

Facilities and coding teams should develop guidance and be sure they fully understand the content and the impact of Coding Guideline #19 to coding practices.

AHIMA 2016 Clinical Documentation Toolkit offers this advice: “Medical necessity and severity of illness can be validated by appropriate documentation. CDI staff can assist in this endeavor by asking questions of providers, who in turn explain in detail why admission occur, and procedure are performed.  It is necessary for providers to take it one step further and completely document the present clinical indicators that caused them to diagnosis the patient with…   If the patient has less clinical indicators that would normally be seen, the provider should document why in the absence of the clinical indicators they still believe the patient has the clinical condition (AHIMA, 2016).”

Coders and CDI staff should review all chart documentation and data and query when necessary to resolve conflict or inconsistency including discrepancies between physician documentation and clinical criteria. Ask the provider to support their diagnostic and procedural documentation by making a specific reference to the clinical basis of the diagnosis and also, noting the absence of specific expected criteria such as, radiographic findings, lab values or patient manifestations. 

Another difficulty is when external auditors fail to follow the same rules and coding guidelines. Reviewers for facilities plagued by copious denials are finding auditors making up their own rules, using obsolete/outdated criteria and clearly not understanding basic terminology used in the IPPS Final Rule.

This type of DRG downgrading may be illegal. Some states, including New York, intend to find out using state level legislation.   It is, at the very least, a blatant disregard for the physician’s clinical judgement. It is the physician that has eyes on the patient and it is important to ask them to document their thought processes, including clinical indicators seen and clinical indicators expected but absent and also their rationale for diagnosis determination.  That…should be enough.

About the Author

Laura Legg

HIM SPECIALIST

Laura Legg, RHIT, CCS, CDIP, AHIMA Approved ICD-10 CM/PCS Trainer, has over 30 years of health information management experience working with acute care hospitals, critical access hospital, and home services.  Laura has worked closely with HRG's HIM department and many healthcare providers nationwide.

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