Coding, Classification & Reimbursement

1.  Clinical criteria may be defined by payers per Coding Clinic

Posted 01-04-2017 11:30

It seems  that Coding Clinic 4th Qt 2016 page 147-149 seems to give payers cover to insist that physicians follow their definition or criteria in making a diagnosis.  This makes it more difficult to appeal denials coming from various payers.

In the 4th Qt Coding Clinic in the last line it states:  

"A facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system.

This will make it more difficult to appeal. Are others having this problem with payers and what can we do? 

Perhaps facilities  can set up their own criteria  that physicians are required to use,for each of the targeted  RAC diagnoses.  If anyone uses that approach, does it help with your appeals where the payer is using a different set of criteria, if you point to your facilities criteria? 

thanks

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Julie
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2.  RE: Clinical criteria may be defined by payers per Coding Clinic

Posted 01-04-2017 20:25
Fair enough, but what if you have a Medicare pt with a secondary payer? Whose criteria on diagnosis take precedence?

The guidelines also state that a licensed provider ALONE may establish a diagnosis. The cited verbiage seems to indicate a payer can insist the provider follow outside guidelines. Nor will the MD be aware of what set of guidelines s/he is supposed to adhere to at one moment versus another...

IMO, this juxtaposition of guidelines is going to create massive headaches down the line.

Deb Kinnard, MPA, RHIA





3.  RE: Clinical criteria may be defined by payers per Coding Clinic

Posted 18 days ago
What are your thoughts on how the 4Qcc 2016 related to clinical criteria and code assignment reads.  There seems to be the interpretation that a coder should never question a provider's documentation or diagnosis made even if it seems to lack the clinical validity or supporting documentation in the record or even if the diagnosis is conflicting, inconsistent or ambiguous.

This CC seems to have caused more problems than help Coders because now this is being interpreted to mean that we shouldn't question any diagnosis documented.

What are your thoughts or how would you reply back to a Coding Manager or Supervisor who uses this Coding Clinic to say just code whatever is documented and don't question it?

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Debra Beisel Denton, RHIA, CCS, CCDS
AzHIMA Coding Roundtable Coordinator
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4.  RE: Clinical criteria may be defined by payers per Coding Clinic

Posted 15 days ago
​We always go back to the basics: UHDDS guidelines for reporting.  If the condition can meet these guidelines, and also make sense with the documentation in the chart and the clinical picture, then it should probably be coded.

There is a slippery slope to making coders use clinical criteria, which has resulted from external audits.  However, if you're reading a chart and come across a diagnosis that is out of left field for the patient and not mentioned anywhere else, then the coder should pause and ensure it is a reportable condition.  We are coders not transcribers. There is always the physician query option also!

It's not a clean black and whit answer, but justifiable.

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Hope this helps
Jennifer Ritter, BS, RHIT, CCS
Coding Manager/Educator
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5.  RE: Clinical criteria may be defined by payers per Coding Clinic

Posted 14 days ago
​Hello!

The cited Coding Clinic differentiates between coding review and clinical review issues.  As others have pointed out, if a provider documents a condition and that condition meets one or more UHDDS criteria, the condition should be coded.  If the condition meets coding criteria for principal diagnosis, it should be sequenced as such.

For example, a provider documents "hypokalemia" and the patient is prescribed a potassium supplement, the condition should be coded regardless of potassium levels recorded in laboratory results.  Even if the potassium levels are "normal", the condition is receiving therapeutic treatment; it has been documented by the provider and meets at least one UHDDS requirement.  Controlled chronic conditions may be coded.  If potassium levels are deemed "not low enough to code", that is a clinical determination.  Clinical determinations are a CDIS issue, not a coding issue.

While in the past coders were trained in the application of clinical criteria, that is no longer the case.  The Cooperative Parties have expressly issued Guidelines that coders are not qualified to make such determinations.  Requiring coders to make such determinations is contrary to The Official Guidelines and Advice.

I would like to point out one excerpt from the cited Coding Clinic, "if the physician documents sepsis and the coder assigns the code for sepsis, and a clinical validation reviewer later disagrees with the physician's diagnosis, that is a clinical issue, but it is not a coding error. By the same token, coders shouldn't be coding sepsis in the absence of physician documentation because they believe the patient meets sepsis clinical criteria. A facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system."  If a coding change is required due to a clinical, rather than a coding review, the change should not be included in the coder's error statistics.  IT IS NOT A CODING ERROR.  If CDIS fails to query the provider, that is a CDIS issue.  Times have changed and official guidance is clear.  Any facility that does not differentiate between coding and clinical errors is not in compliance with official advice.  I also believe requiring coders to apply clinical criteria is also a violation of the official advice.  I also believe any such clinical changes should be brought to the appropriate provider's attention for comment.

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Lawrence Barr
President
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