The current set of ICD-9-CM coding guidelines won’t change due to the code freeze. However, that doesn’t mean that certain pesky guidelines won’t continue to challenge—and frustrate—even the most seasoned coders.
Choosing a principal diagnosis
Coders still struggle with principal diagnosis selection, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, manager at Accretive Health in Chicago. “Coders are too dependent on the encoder. They push the analyzer button to see which one pays the most.”
The ICD-9-CM coding guideline pertaining to principal diagnosis selection states the following:
The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as ‘that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.’
Coders must look at the history of present illness as well as the presenting signs and symptoms. Does this information match up with a potential principal diagnosis? The link should be clearly documented, says Krauss. If it’s not, the coder may need to query the physician.
Choosing a principal diagnosis when two or more diagnoses appear to equally meet the definition of principal diagnosis is particularly problematic because it forces coders to look at documentation under a microscope, says Krauss. The relevant ICD-9-CM guideline states the following:
In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.
“It says ‘in the unusual circumstance,’ but it’s not that unusual,” says Krauss. On the surface, many diagnoses may appear as though they meet the definition. If coders don’t take their time when reviewing documentation, they can easily overlook the correct principal diagnosis.
For example, a patient presents with chronic obstructive pulmonary disease (COPD) and pneumonia. Either condition can potentially be managed on an outpatient basis. Coders must dig deeply into the documentation to see which one prompted the admission—not automatically default to condition that yields the higher payment. In this case, documentation of ‘COPD stabilized in the ED’ is a big clue that the COPD should not be the principal diagnosis, he says.
“[The co-existing guideline] is one that has been around for a while,” says Nelly Leon-Chisen, RHIA, director of coding and classification at the American Hospital Association in Chicago. “When the Cooperating Parties developed this guideline … we really meant in the unusual circumstance.”
However, Leon-Chisen admits that today’s more stringent admission criterion means that patients often present with multiple conditions. “People used to get admitted much more easily than you do today,” she says. “Perhaps this is where it’s getting more confusing because people are coming in with more serious problems, and coders are having more trouble. People are not admitted at the first sign of a problem. They have multiple conditions.”
Coders must consider the following, says Leon-Chisen:
- Could any of the patient’s multiple conditions have been treated on an outpatient basis?
- Did the patient have an acute flare-up of one of the conditions? If so, did that prompt the admission?
- Do any instructions in the alphabetic or tabular indices indicate which diagnosis should be reported as principal?
- Did one diagnosis require more invasive testing and/or surgery?
- Must the physician be more specific in his or her documentation in terms of what diagnosis occasioned the inpatient admission?
Reporting secondary diagnoses
Determining whether to report a secondary diagnosis can also be challenging. The relevant ICD-9-CM guidelines state the following:
For reporting purposes the definition for ‘other diagnoses’ is interpreted as additional conditions that affect patient care in terms of requiring:
- clinical evaluation; or
- therapeutic treatment; or
- diagnostic procedures; or
- extended length of hospital stay; or
- increased nursing care and/or monitoring.
The UHDDS item #11-b defines Other Diagnoses as ‘all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.’
The key to compliance is determining whether a condition warranted further workup, says Krauss. “Just because there is an abnormal lab value doesn’t mean that it’s significant,” he says. He cautions coders against reporting diagnoses simply because clinical documentation improvement (CDI) specialists ask for clarification of those conditions. The presence of a CDI query doesn’t necessarily imply that the condition is a codeable secondary diagnosis, he adds.
Looking ahead to ICD-10-CM/PCS
“In the ICD-10-CM guidelines, we’ve tried very deliberately to keep the concepts consistent unless there was something inherent to ICD-10 that would make it different,” says Leon-Chisen. Coders can currently download the 2014 ICD-10-CM coding guidelines as well as the 2014 ICD-10-PCS coding guidelines.
Leon-Chisen says the Cooperating Parties also considered provider feedback. For example, she says providers have indicated that some payers don’t accept ICD-9-CM code V57 as the principal diagnosis when a patient is admitted for rehabilitation. Instead, payers have requested that coders report acute problem even though it’s no longer present.
For example, a patient is admitted to address hemiplegia from a stroke. Some payers request the stroke—not V57—as the principal diagnosis even though this contradicts official coding guidelines, she says.
In ICD-10-CM, coders will no longer report a code for the encounter for rehabilitation as the principal diagnosis. The ICD-10-CM guidelines provide the following instruction:
When the purpose for the admission/encounter is rehabilitation, sequence first the code for the condition for which the service is being performed. For example, for an admission/encounter for rehabilitation for right-sided dominant hemiplegia following a cerebrovascular infarction, report code I69.351, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, as the first-listed or principal diagnosis.
If the condition for which the rehabilitation service is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis. For example, if a patient with severe degenerative osteoarthritis of the hip, underwent hip replacement and the current encounter/admission is for rehabilitation, report code Z47.1, Aftercare following joint replacement surgery, as the first-listed or principal diagnosis.
Ensuring compliance
Coders must absolutely have the official coding guidelines ready and waiting at all times, says Leon-Chisen. This includes bookmarking them, saving them to one’s desktop, or even printing out a copy. New coders, in particular, should access them regularly, she adds.
Editor’s note: Eramo is a freelance writer and editor in Cranston, R.I., who specializes in healthcare regulatory topics, health information management, and medical coding. You may reach her at leramo@hotmail.com.