September 12, 2016

Clinical Indicators for Code Assignment – Deeper than Just Coding

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The new guideline instructing coders not to use clinical indicators for code assignment has generated considerable interest. I have received many emails from colleagues, and even some from physicians, voicing concerns or sharing enthusiasm for coding and documentation integrity.

No matter what your stance is on this guideline, it is clear to me that the timing of the cooperating parties officially putting these words in the coding guidelines comes when the waters of coding and auditing have become muddied at best. I have little doubt that the use of clinical indicators has been and continues to be abused on both sides of the coding coin. On the payer side, the absence of clinical indicators has been used to their advantage, and as a basis to require facilities to return money. On the hospital side, some facilities are using clinical indicator coding as a form of offense against those payer audits. It’s your standard cat-and-mouse game.

Then we have the physicians. Where do they fit in? One physician, Ronald Hirsch, MD, a physician advisor, had this to say: “I wish I could share your enthusiasm for the integrity and accuracy of physician documentation. As a physician, I can attest that it is very common for doctors to document things that do not exist. I think the origin was with the need for appropriate diagnoses to get tests authorized.” 

“It’s a tough situation,” Hirsch went on to say, “but I absolutely agree that coders should not be the ones clinically validating diagnoses.” 

It’s no secret that physicians, hospitals, and patients often are caught in the middle of this tug-of-war. Regulations often require “typical” symptoms or conditions to be present for patients to obtain necessary diagnostic tests. Doctors often suspect patients have a condition based on “atypical” symptoms, but need the diagnostic tests for confirmation.

Patients cannot get the necessary diagnostic tests without meeting specific clinical criteria. Hospitals don’t get paid for patient services unless coding and quality criteria are met. Payers are using clinical criteria to generate reimbursement paybacks. It’s enough to make your head spin. 

So, who suffers? We all do. Doctors get frustrated and overwhelmed by the avalanche of documentation improvement requirements, which distracts from purely caring for patients. Patients may not get the medical intervention they need. Hospitals are losing money. Coding and billing departments are dealing with mountains of denials due to lack of clinical validation in the documentation. Coding and compliance departments are trying to figure out how to navigate the myriad regulations. 

So, what do we do now? As Dr. Hirsch so aptly stated, it’s a tough situation – and a problem not easily solved. Some in the industry are reaching out to their state hospital associations for assistance, because the DRG denials by third-party review companies has reached out-of-control levels. Some have physicians and politicians on board in this battle, looking to take the matter even further to enact laws forcing third-party reviewers and carriers to follow the federal coding guidelines.At the facility level, this new coding guideline may assist in the defense of our coding and documentation. We need to continue querying physicians for clarification and documentation improvement efforts. 

One thing is certain – this new guideline cannot be ignored, and is here to stay. 

We may need to fasten our seat belts as we watch for the effect it has on the industry.
Sandra L. Brewton, RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer

Sandra L. Brewton, RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer, is a senior healthcare consultant for Panacea Healthcare Solutions, a Career Step company. She has more than 20 years of experience in health information management (HIM). Her responsibilities at Panacea include inpatient record audits, recommendations for medical records operations and coder/provider training in documentation quality improvement and ICD-10 and CPT® coding guidelines. Previously, Sandra supervised the inpatient coding department of a major university healthcare system.

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