Coding Clinic for CDI: Review of Third and Fourth Quarter 2016

CDI Blog - Volume 9, Issue 62

by Sharme Brodie, RN, CCDS
The AHA’s Coding Clinic for ICD-10-CM/PCS had both its third and fourth quarter 2016 editions published at the same time this fall. The combined publication is very long—the longest I have ever reviewed—so let’s start by looking at some of the changes to the ICD-10-CM Official Guidelines for Coding and Reporting.

Trouble with ‘with’
As many of you have probably heard, Section A.15 of the new Guidelines states that any time the word “with” appears, either in the Alphabetic Index or in an instructional note not in the Tabular List, the classification presumes a causal relationship and the conditions will be linked even in the absence of provider documentation. Coding Clinic reiterates this fact. For CDI specialists, this may seem like a good thing, but it also means we need to do our homework and make sure all these assumed relationships are truly related. We may find we need more queries to verify these cases with the providers. So be careful and go over each case to make sure it is an accurate representation of what is going on with your patients.

Providers’ prerogative
Coding Clinic (p. 119) stresses the new Guidelines found in Section A.19, which state that assignment of a diagnosis code must be based on the provider’s diagnostic statement that the condition exists, not on clinical criteria used by the provider to establish the diagnosis. That’s not to say the clinical criteria don’t matter, but that coders and CDI specialists cannot decide when a condition exists based on whether we feel certain criteria are appropriate for a condition.

According to Coding Clinic (p. 8), coders have questioned whether ICD-10-CM codes for sepsis may be assigned based on the new clinical criteria that were released in February 2016, The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). This Coding Clinic states “coders should never assign a code for sepsis based on clinical definition or criteria or clinical signs alone.”

Editor's Note: There's a lot more to cover in these oversized editions of the fall 2016 Coding Clinic, and Brodie explores the highlights in an extended white paper available in the Resources section of the ACDIS website. Brodie is a CDI education specialist for HCPro in Middleton, Massachusetts. Contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com.