New coding guideline contradicts quality program auditing policies

November 16th, 2016

The Workgroup for Electronic Data Interchange (WEDI) has released an issue brief on clinical documentation and the 2017 ICD-10 Official Guidelines. According to WEDI, the new coding guideline conflicts with reporting and auditing policies for several quality programs, as well as medical necessity rules and other healthcare regulations.

As broken down in a recent RevCycle Intelligence article, the coding guideline that allows diagnostic statements rather than clinical documentation to determine codes contradicts auditing policies for quality programs. The 2017 guidelines include a specific provision about clinical documentation. In guideline 19, CMS discusses code assignment and clinical criteria:

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists,” the guideline states. “The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

According to WEDI, this guideline has caused considerable concern throughout the healthcare industry, especially in light of quality program reporting and auditing. Processes currently in place call for specific clinical coding and documentation. “While this guideline puts in writing what is an age old process, current regulations, medical necessity requirements and audit programs negate this type of coding,” WEDI wrote in the issue brief.

As a result, the organization sought to clarify confusion regarding clinical documentation and ICD-10 coding. “We believe the intent of guideline 19 was to let coders know that if they did not have the ability to query the provider, the provider’s written statement could be used for coding purposes,” WEDI said.

Why all the Confusion?

Because if coders can simply rely on the written diagnosis statement from the doctor, there may be a disconnect between the ICD-10 code and the clinical documentation in the EHR which – you guessed it – could negate all efforts for clinical documentation improvement. WEDI advises that organizations take a look at how they previously handled situations where there appears to be a disconnect between the physician’s diagnosis versus other clinical documentation, and where possible, to query the physician in order to validate the statement and to confirm why the documentation differs.

The ICD-10 coding guideline also contradicts a recent FAQ on the CMS website which aims to increase ICD-10 coding specificity. Since the industry is no longer in the grace period (which ended on October 1), WEDI emphasizes that providers should currently code to the highest level of specificity. This is another effort to improve clinical documentation accuracy.

Clinical documentation improvement is not only vital for patient care, but helps in transition to value-based care programs. As providers continue participating in meaningful use programs and begin reporting to the Quality Payment Program, it will be important that they continue with clinical documentation improvement. In other words, what we need is clarification – not contradiction – in order to continue the ongoing effort to improve clinical documentation throughout the industry.

There is always opportunity for education industry-wide for CDIs to explain to those physicians who have been hard to reach that those unspecified codes are no longer going to be paid. We can prepare you with our EduCode® Clinical Documentation Improvement tools, which can help you identify critical documentation requirements based on settings and type of service provided and assess your staff proficiency.