Over the many weeks since the release of the updates to the ICD-10-CM Official Coding Guidelines for the 2017 fiscal year, I have had the opportunity to engage in multiple conversations about the most controversial guideline, which addresses the use of clinical indicators for code assignment. Some of those conversations have involved fellow auditors, while some involved coders and coding leadership.
Yet the most intriguing and enlightening conversations I’ve had on this subject have involved physicians. I recently had the opportunity to dialogue with a physician consultant about this specific guideline and its implications. She responded to an article I wrote in which I mentioned the problematic documentation of patients listed as intubated for airway protection for whom acute respiratory failure later is documented as the diagnosis. This documentation scenario is difficult for coding staff, because it involves conflicting documentation. At the point when the conflict becomes clear, the coder has to send a query for clarification to the attending physician. Another problem with this scenario is that even when the query comes back affirmative for the patient’s diagnosis being acute respiratory failure, the presence of documentation stating “intubation for airway protection” continues to cast doubt on the diagnosis, sending a red flag to auditors on a condition that has numerous red flags attached to it already.
This physician advisor also shared her perspective with me on “airway protection,” noting that she often educates physicians on just how rare that condition is. One of the most interesting things she shared with me is that she feels that providers often don’t know what they are documenting and what the implications of it are. That statement got me thinking that she is probably more right about that than most of us know.
As coding departments beat their heads against the same proverbial wall over and over again to try to improve physician documentation, perhaps most physicians don’t realize just what implications their particular documentation has on the billing process and how it could potentially affect the patients themselves.
So, does this new guideline let physicians off the hook in their documentation practices? The short answer is that it could. I don’t believe this is an intended consequence of this new guideline, but it could be an unintended one. But most physicians don’t read the coding guidelines and don’t use coding guidelines when they are documenting in patient charts regardless, so many physicians may not be aware of the existence of the new guideline.
I think it is important that we let physicians be physicians and encourage them to document their thought processes and care of their patients thoroughly. Physicians really don’t need to understand this new guideline. Physicians’ focus should remain on documenting their diagnoses and justifying them with plenty of evidence of clinical indicators and what lines of thinking brought them there. Anything less than this could be seen not only as suboptimal documentation, but suboptimal medicine.
The bottom line is, if physicians support their diagnoses clinically in their documentation, then the coding staff won’t have to rely on a guideline in an ICD-10 book for proper payment.