Use Coding Clinic wisely and correctly for ICD-10

Coders and clinical documentation improvement (CDI) specialists may not always agree with the advice provided by the American Hospital Association's Coding Clinic, but the publication can serve as a sort of judge and jury for confusing coding situations.

 

“Whereas the ICD?9?CM or ICD?10?CM/PCS transaction sets, supplemented by the guidelines, are the Constitution, Coding Clinic serves as the Supreme Court in interpreting ICD?9?CM or ICD?10?CM/PCS and their guidelines,” says James S. Kennedy, MD, CCS, CDIP, president of CDIMD in Smyrna, Tennessee. Coding Clinic’s advice is official.

 

Coding Clinic wants to get things right, Kennedy says. In fact, in the First Quarter 2014, Coding Clinic stated that its advice is not about reimbursement. It should be used to get the coding correct.

 

However, coders and CDI specialists should be careful not to look at Coding Clinic in a vacuum, Kennedy says. They also need to follow the coding hierarchy for diagnosis coding in ICD-10-CM.

 

Start with the ICD?10?CM Index to Diseases. Look terms up here first. “The index in many cases drives the bus,” Kennedy says.

 

Next, go to the ICD?10?CM Table of Diseases, which offers additional instructions, such as “code first,” “code in addition,” “in diseases classified elsewhere,” “Excludes1,” “Excludes2,” and other notes, Kennedy says.

 

The ICD?10?CM Official Guidelines for Coding and Reporting may add or subtract codes or influence sequencing. “If you want cheap education about what ICD-10 is, download the guidelines and read them,” Kennedy says.

 

Then consider advice from Coding Clinic for ICD?10?CM/PCS, which may add or subtract codes or influence sequencing. Occasionally, Coding Clinic can overrule the Index, Table, and Guidelines, Kennedy says.

 

At the bottom of the hierarchy are court opinions or other payer?specific regulations.

 

Coders and CDI specialists need to follow a similar hierarchy for ICD-10-PCS codes, Kennedy says.

The ICD?10?PCS Index is one place to start. The purpose of the Alphabetic Index is to locate the appropriate table that contains all information necessary to construct a procedure code. In some cases the index will list the entire code. In other cases, it will only list part of the code. Either way, coders should always consult the ICD-10-PCS Tables to find the most appropriate valid code.

 

However, coders don’t have to start at the index. They can proceed directly to the tables to choose the correct code.

 

The ICD?10?PCS Official Guidelines for Coding and Reporting may add or subtract codes or influence sequencing.

 

Coders have an additional resource for ICD-10-PCS: the ICD?10?PCS Reference Manual, a supplemental guide developed by 3M through a contract with CMS.

 

Next, consider advice from Coding Clinic for ICD?10?CM/PCS, which may add or subtract codes or influence sequencing. In some cases, Coding Clinic can overrule the Index, Tables, and Guidelines just as with ICD-10-CM.

 

Finally, be sure to review any court opinions or other payer?specific regulations.

 

Coding Clinic guidance is not always set in stone and unchanging, cautions Kyra Brown, RHIA, CCS, AHIMA?approved ICD?10?CM/PCS trainer, CDI manager/educator for Erlanger Health System in Chattanooga, Tennessee.

 

“You can’t hang your hat on older Coding Clinics,” Brown says. Unfortunately, not all coders are current on Coding Clinic. That could present significant challenges after the transition to ICD-10.

 

Coders don't have to throw out Coding Clinic advice for ICD-9-CM, but they do need to be careful when applying it in ICD-10-CM, says Nelly Leon-Chisen, RHIA, director of coding and classification for AHA in Chicago.

 

Consider gangrene and diabetes. In ICD-9-CM, coders can assume a cause-and-effect relationship between the diabetes and the gangrene as long as the physician does not document any other causes of the gangrene (Coding Clinic, First Quarter 2004, pp. 14-15).

 

Coders cannot assume a relationship between diabetes and gangrene or osteomyelitis in ICD-10-CM, Leon-Chisen says. The physician needs to make the connection (Coding Clinic, Fourth Quarter 2013, p. 114).

 

Coding Clinic has also changed its stance on retained surgical objects in Coding Clinic for ICD?9, First Quarter 2014, p. 14.

 

A patient underwent an emergent low transverse cesarean section. The surgical team deferred the sponge counts during surgery because they had no initial count. Instead, they planned to conduct post-operative x-rays. The x-ray findings suggested a retained laparotomy sponge. The surgeon opened the patient back up in the operating room and removed the retained sponge without complication.

 

Coding Clinic initially instructed coders to assign ICD-9-CM code 998.4 (foreign body accidentally left during a procedure). In ICD-10-CM, coders would report T81.500A (unspecified complication of foreign body accidentally left in body following surgical operation, initial encounter).

 

However, the patient didn’t leave the operating room and suffered no actual complication, Kennedy says.

Coding Clinic revisited the case in Third Quarter 2014, pp. 35–36 and issued a correction. Because the patient did not leave the operating room, coders should not report a complication code. The timeframe for when the sponge was discovered is the key detail, Brown says.