Are ICD-10-CM coding guideline 19 and clinical validity diametrically opposed?

Oct. 7, 2016 / By Sue Belley, RHIA, Cheryl Manchenton, RN, Donna Smith, RHIA

Cheryl:  Hey fellow bloggers, have you heard what people are saying about the new ICD-10-CM coding guideline 19?

Sue: I’ve heard a few things. . .

Donna: There’s certainly a lot of chatter and quite a few blogs have been written about it. Cheryl, what are you hearing?

Cheryl:  Every client I’ve spoken to recently has commented on it and the general consensus is that guideline 19 prohibits the clinical validity process and is in direct conflict with the AHIMA/ACDIS Practice Brief on Querying.

Donna: But this is a coding guideline, not a documentation guideline. The guideline says code assignment is not based on clinical criteria.

Sue: Actually, I think this guideline takes the burden off coding professionals who are put in the uncomfortable position of determining the clinical validity of diagnoses documented by the provider, which are out of the scope of their practice. I have been involved in conversations about the possibility of penalizing coding professionals on their coding accuracy scores if they code documented diagnoses such as sepsis without determining the clinical validity of the diagnosis.

Donna: I have also heard of facilities that ask coding professionals to determine the clinical validity of sepsis based on the criteria outlined in a Coding Clinic article, which was actually not the purpose of the Coding Clinic article.

Cheryl: What I find concerning are organizations that establish a coding policy that does not allow coding professionals to code a diagnosis documented by a physician when the diagnosis does not meet clinical criteria defined by the institution.

Sue: Determining the accuracy of documentation should remain in the clinical hands of physician advisors, clinical documentation improvement specialists (CDIS), chief medical officers, etc. Whatever happened to physician peer review of the adequacy/accuracy of clinical documentation?

Donna: I think every organization should be encouraged to establish a clinical validity and escalation policy.

Cheryl: Do we all agree that when the clinical validity and escalation policy does not result in changes to the documentation in question, the coding guideline clearly states it is to be coded as documented?

Sue:  Yes, the diagnosis must be coded.

Donna: I also want to mention that copy/paste is an associated problem that requires clinical validity in order to determine the accuracy of the diagnosis during the current encounter.

Cheryl:  Agreed! Part of clinical validity is ensuring that the patient’s problem list is not outdated and inaccurate so coding professionals can appropriately capture everything documented.

Sue:  So, what we’re saying is that clinical validity and guideline 19 are not diametrically opposed. Clinical validation can and should take place, but it needs to be done by a clinician’s validation

Cheryl: Yes, with the objective that coding should match documentation and documentation should be accurate.


Sue Belley, RHIA, clinical content development manager, consulting services, 3M Health Information Systems.

Cheryl Manchenton is a senior inpatient consultant and project manager for 3M Health Information Systems.

Donna Smith, RHIA, senior consultant and project manager, consulting services, 3M Health Information Systems.