Coding, Classification and Reimbursement

Outpatient Coding Policy Guidance and EHR's & Coding Selection

  • 1.  Outpatient Coding Policy Guidance and EHR's & Coding Selection

    Posted 12-28-2018 11:38
    ​​​Hello Everyone,

    Our providers are able to associate a code to their description when performing outpatient order entry via EHR.

    When we code an outpatient order, sometimes the description/code generated from their EHR (which is on the electronic order) does not match what is in the coding manual.  This could be for multiple reasons: set up errors, education needed, accidently clicked on wrong description, didn't click on more descriptive option-documented, etc.

    My question is: Is there a policy which defines what we are required to use to code: should we be using the ICD10 number or the description on the order? I don't want it to seem like we are changing the "code" the physician entered on the order.

    Looking for policy guidance.

    Thank you,

    Kathy Shemka
    HIMS Manager
    Scheurer Hospital

  • 2.  RE: Outpatient Coding Policy Guidance and EHR's & Coding Selection

    Posted 12-28-2018 12:24
    Hi, Kathy. 

    There was a Coding Clinic originally posted in 2012 for ICD9, but it was updated in 2015 for I10.

    Code number in lieu of a diagnosis 
    ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2015 Pages: 34-35 

    "Yes, there are regulatory and accreditation directives that require providers to supply documentation in order to support code assignment. Providers need to have the ability to specifically document the patient's diagnosis, condition and/or problem. It is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement. ICD-10- CM is a statistical classification, per se, it is not a diagnosis. Some ICD-10-CM codes include multiple different clinical diagnoses and it can be of clinical importance to convey these diagnoses specifically in the record. Also some diagnoses require more than one ICD-10-CM code to fully convey the patient's condition. It is the provider's responsibility to provide clear and legible documentation of a diagnosis, which is then translated to a code for external reporting purposes."

    Regina Sanders RHIT, CCS

  • 3.  RE: Outpatient Coding Policy Guidance and EHR's & Coding Selection

    Posted 12-29-2018 11:53
    It sounds like the Nushield was just used to minimize adhesions. There is a Coding Clinic 3Q 2015 pg 29 that states "The placement of the adhesion barrier during surgery is not coded separately, because it is a surgical supply, and integral to the definitive procedure. If facilities wish to track the use of adhesion barrier during surgical procedures, the codes are located in table 3E0 and are applied to a limited selection of anatomical regions."  There is another Coding Clinic 1Q 2018 pg 9 that supports assigning a code if the intent of the material was used to supplement or augment rather than as an adhesion barrier substance adjunct to surgical wound closure.

    Karen Neal
    Coding Quality Auditor
    Conifer Health Solutions