Inside Angle
From 3M Health Information Systems
Are ICD-10-CM coding guideline 19 and clinical validity diametrically opposed?
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.
4 thoughts on “Are ICD-10-CM coding guideline 19 and clinical validity diametrically opposed?”
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Sue Belley, RHIA
Clinical content development manager, consulting services and outsource services
Susan Belley, M.Ed., RHIA, CPHQ, is the manager of clinical content development and the manager of outsource services within the consulting services business of 3M Health Information Systems. She is…
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Cheryl Manchenton, RN
Project manager, quality services lead
Cheryl Manchenton, RN, BSN, CCDS, CPHM, is a senior inpatient consultant/ project manager/3M quality services lead with 3M Health Information Systems, overseeing clinical documentation integrity (CDI) programs. She is a…
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Donna Smith, RHIA
Senior Consultant and Project Manager, Consulting Services
Donna Smith, RHIA, is a senior consultant and project manager with the Consulting Services business of 3M Health Information Systems. As a member of the 3M ICD-10 development team, she…
Thank you so much for sharing your perspective. I wholeheartedly agree!! My first thought was this new guideline is the Cooperating Parties’ response to the dangerous drift that has occurred (particularly with payers) in overreaching interpretation and application of coding guidelines. It restores coders to their critical role of accurately classifying—not interpreting—diagnoses and procedures documented in the patient record. Some have stated this new guideline negates the need for clinical documentation efforts. I believe it actually strengthens the importance of the CDI role, and I don’t see that changing anytime soon.
Thanks Kaelyn! We agree with your comments and feel that it further supports the need of a CDI program and for clinical validation outside of the HIM scope
We have also have in-depth conversations regarding this guidance. We have found it really helps clarify the role of the coder/HIM personnel and the clinical component. In response we have developed a Clinical DRG Validation Escalation Process that incorporates CDI in helping to identify and query for clinical clarification. Then if it remains unclear have established a Physician Peer Review Escalation Process that includes reporting/documenting through a Quality Reporting Mechanism. We track 1) whether an encounter had to be escalated for physician advisor review, 2) did the attending complete the documentation addendum and 3) was the addendum completed with a 5 day timeframe clarification addendum. Clinical Validation has always been present, it just seems it wasn’t always emphasized as part of the DRG validation process as a whole.
Thanks for your thoughtful response. We agree with the separate of roles per se. We also want to ensure that everyone understands that if the clinical validity process “fails” that coding cannot not assign a code for the documented diagnoses. We agree with the depth of your process and salute your hard work!