The code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

Referring to the contentious ICD-10-CM Guideline I.A.19, which indicates that assignment of a diagnosis code is based on the provider’s diagnostic statement that a condition exists, Erica Remer, MD said during Tuesday’s Talk-Ten-Tuesdays broadcast that it is frequently bandied about as the reason why coders code diagnoses: because the doctor said so.

“I hypothesize that the Guideline’s true purpose was to prohibit coders from assigning codes to conditions (that) might be inferred from clinical indicators and criteria, instead requiring the provider to make a definitive (or uncertain), explicit declaration of the condition,” Remer said.

“Is a potassium of 6.9 hyperkalemia?” Remer asked. “It may be; the level is high enough to satisfy the diagnosis of hyperkalemia, but are there extenuating circumstances (that) would deter the provider from drawing that conclusion? Is the specimen hemolyzed in a patient with normal renal function, on no meds prone to causing hyperkalemia?”

“It requires a clinician to use their clinical judgment to make the determination of the significance of the elevated potassium,” Remer added. “A coder can’t, and may not, just compare to the normal range and conclude and code that the patient has a medical condition, based on the value.”

Remer also noted, however, that if a provider makes a diagnosis using their medical judgment, the coder shouldn’t discount it if “the patient didn’t read the textbook.” Remer said that if a clinician believes a patient has bacterial endocarditis, but doesn’t tick off enough major and minor criteria to meet the formal definition of infectious endocarditis, the coder should not reject the diagnosis out of hand; she noted that the best practice is for the provider to explain their thought process.

“When I read guideline I.A.19, I wonder to myself, ‘the fact that the provider said it may be sufficient … does that mean it is mandatory to code it?’” Remer asked rhetorically. “Even the most seasoned medical coder is not a clinician. If said coder, or perhaps a less experienced coder, questions whether the diagnosis is really present or not, wouldn’t you imagine that an auditor or a lawyer might be wondering the same thing?”

Remer said clinical validation is an ever-expanding issue. The reality is that the only one who can affirm that a diagnosis is clinically valid is a provider who has personally evaluated the patient.

“The rest of us are going on what is recorded in the chart,” Remer said. “If we have a concern about clinical validity, what we really have is a concern that the documentation as it stands does not seem to support the diagnosis offered.”

Remer told Talk-Ten-Tuesdays listeners that if coders or clinical documentation integrity specialists (CDISs) have a question about whether a diagnosis is legitimate, they may be permitted to code it in accordance with Guideline I.A.19, but this doesn’t mean they should or have to. The wisest approach, Remer said, is to generate a clinical validation query and have the provider either confirm the diagnosis and beef up their documentation or remove the diagnosis because it isn’t present.

During the Talk-Ten-Tuesdays broadcast, a listener asked if it is incorrect to code the condition documented by the provider. There wasn’t enough time to address it on air, but Remer said afterwards that according to the Guideline, it is sufficient simply to code the condition. However, if the coder/CDIS knows the condition to not be present and codes it anyway, that would not be compliant coding.

“At (the) very least, you would be risking a denial down the road, and at worst, you would be submitting a false claim,” Remer responded. “That is a big no-no called ‘fraud.’ Don’t do that! If you are unsure, a clinical validation query is indicated.”

The listener further asked if it is a clinical documentation integrity (CDI) issue, a coder issue, or both. Remer’s answer is that whoever recognizes that there is a clinical validity issue should initiate their institution’s clinical validation process.

“We want the documentation and the codes to be accurately depicting the patient encounter,” Remer cautioned. “Don’t let Guideline I.A.19 prevent you from getting to the truth,” she added.

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