ICD10monitor and RACmonitor have been covering the controversy that the release of the 2017 ICD-10 Official Coding and Reporting Guidelines has drummed up yet again.

Two excellent articles this past week were “Coding Conundrum: Clinical Indicators for Code Assignment” by Sandra Brewton, RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer; and “Developing: Clinical Validation versus DRG Validation” by Allen Frady, RN, BSN, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer. 

These two articles offer great background on the issue and provide an excellent description of the current environment. This issue, however, is not new; it has been around since DRGs first started to be used back in the 1980s – I remember this because I was a concurrent coder back then. 

To help understand how our coding professionals are coding, we polled our listeners on last week’s (Aug. 23, 2016) Talk-Ten-Tuesdays broadcast, asking them: which statement below best describes how your coding professionals assign codes?

  • Option 1: Query physician but assign codes based on clinical criteria regardless of query response and physician documentation (9 percent)
  • Option 2: Query physician and assign codes based on physician query response and documentation regardless of clinical criteria documentation (52 percent)
  • Option 3: Skip the query and assign codes based on clinical criteria regardless of physician documentation (1 percent)
  • Option 4: Skip the query and assign codes based on physician documentation regardless of clinical criteria documentation (10 percent)
  • Option 5: I’m not sure what our coding professionals do (7 percent)
  • Option 6: Our physicians do their own coding (2 percent)
  • Option 7: Other (8 percent)
  • Option 8: Not applicable (11 percent) 

As you can see, the majority of respondents, 52 percent, indicated that their coding professionals query the physician but then assign codes based on the physician documentation regardless of the clinical indicators. Another 10 percent said that they do not query (we would always recommend a query) but would do the same, assign codes based on the physician documentation.

Going way back to the beginning of my career as a coding professional, I was always told that I am not a physician and therefore cannot make decisions on diagnoses and treatments – which made perfect sense to me. We, however, as coding professionals, have a responsibility to be well-educated enough that we can query the physician when needed to try and determine the appropriate codes when documentation is unclear or conflicting. We also rely on clinical documentation improvement (CDI) specialists (who are usually nurses, and sometimes coding professionals) to query the physician concurrently, while the patient is still in the hospital, to try and obtain clear documentation. When coding and CDI professionals work together, the result is much more complete documentation so that accurate codes can be assigned.

We must also remember that physicians and coders often do not speak the same language. What an ICD-10 code or coding guideline might say may not be how or what a physician understands it to be, based on what he or she learned in medical school. This was often pointed out by our late and very good friend Dr. Robert Gold.

Add to this the regulatory auditors that have a mix of backgrounds and education, who don’t always follow the rules, and who sometimes appear to look for ways to deny claims in the hopes that facilities and providers will just give up with their appeal process and accept a denial (and usually, decreased payment). 

There are official coding guidelines that coding professionals have to follow. What official auditing guidelines do the Recovery Auditors (RAs) have to follow? Why can they deny claims, often loosely based on clinical indicators, when we can’t code based on them? Now, I certainly realize that this is a gray area, as Allen speaks to in his article. But I also believe that if a little more common sense was applied from the auditing side, the number of denials could be reduced to those for which there is a significant lack of clinical indicators, where perhaps an initial query was not generated or the physician did not respond to the query or a code was assigned incorrectly. 

In conclusion, with the number of denials currently occurring and being overturned, I think it is time that official auditing guidelines are established for all RAs – and that they be made public. This will help facilities and providers know what the auditing criteria are, just as they know what the coding guidelines are. Everyone would be working from a level playing field. In my opinion, this is just common sense, and it’s high time we get back to common sense when coding and auditing records.

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