Coding, Classification & Reimbursement

1.  MD lists Diagnoses-one has Excludes code

Posted 05-17-2017 07:04
I have a physician that has listed 3 codes for a particular outpatient infusion.  One of the three cannot be coded with one of the most relevant for the infusion because the most relevant has an excludes code.  It will not change anything if they don't use that 3rd code.  They will have the first 2 which fit the infusion perfectly.  Do I need to go back to the physician and ask that they take that 3rd code off?  It took almost a year to get them to put a diagnosis on the script at all.  I need authoritative documentation in the answer as I am facing a big department.  I've looked in the coding clinic but cannot really find anything.  Thanks for your help.

2.  RE: MD lists Diagnoses-one has Excludes code

Posted 05-18-2017 08:47
Your documentation would be the excludes note in the code book.  A physician may list several diagnoses on a script or record, but coding guidelines are still going to be the final authority on what can actually be coded or not coded.  I would not ask the physician to change the order because if the record gets audited and the diagnoses are listed, you are still required to follow coding guidelines.  Your documentation is coding guidelines, excludes notes and coding clinic.

Good Luck!

M Carmella Mercer, CDIP, CCDS, CCS
CDI Specialist
Tift Regional Medical Center

3.  RE: MD lists Diagnoses-one has Excludes code

Posted 05-18-2017 10:58
Dear Linda,

If it will not make a difference, then I would just leave it alone. You do not want to burn your bridges on something that will not matter in the end. Better to save it for something a lot more costly.

Jodi Miller, RHIT, CCS

Jodi Miller, RHIT, CCS

4.  RE: MD lists Diagnoses-one has Excludes code

Posted 05-19-2017 08:26
I would not ask the physician to remove the code.  However, you still need to adhere to coding guidelines in determining which codes will be reported on the claim.  I don't know what the process is at your facility in regards to who is responsible for coding the diagnoses.  If your facility's expectation is that the codes assigned by the physician are to be the codes reported on the claim then it sounds like you will need to talk to the physician and seek clarification.  I have provided some talking points below.

The ICD-10-CM is a classification system.  The purpose of a classification system is to categorize/group/organize things according to shared qualities or characteristics.  This is important to note because it is not the intention of the ICD to be a nomenclature.  Even though more and more specific codes are introduced into ICD-10-CM every year, the ICD is still not a naming system and it is not intended to provide a unique code for each unique condition.

Perhaps it would be helpful to sit down with the physician to see how he/she arrived at the codes assigned (Yes, I am serious).  If you have followed the guideline for locating a code in the ICD-10-CM (described in official coding guideline I.B.1) and if you have adhered to the ICD-10-CM Official Guidelines for Coding and Reporting and the ICD-10-CM coding conventions (which are described in guideline I.A), then I suspect that you have correctly performed the process of classifying the conditions documented on the physician order to the appropriate codes.  If the physician has not followed the process for assigning a code as required by the conventions and guidelines then explain to the physician where the process was not followed.

45 CFR 162.1002 provides information on the code sets that are required.  You will see that the ICD-10-CM Official Guidelines for Coding and Reporting are included as part of the code set.  That means adherence to these guidelines is required by all covered entities who use the ICD-10-CM codes to report conditions on electronic claims.

If you are looking for an example of a nomenclature you do not have to look any further than to the CPT codes.  The CPT book is a systematic listing of proper names for procedures and services.  The process of CPT coding is different from the process of ICD-10-CM coding.

Judy Bielby
Clinical Assistant Professor
University of Kansas Medical Center