Guest post: Exploring the importance of best practices for coding guidelines

by Crystal Stalter, CDIP, CCS-P, CPC

In addition to EHR use best practice which we discussed last week, another example of best practice for coding, CDI, and HIM, is following the ICD-10-CM Official Guidelines for Coding and Reporting. When coding, first seek the code in the Alphabetic Index, but then use the Tabular List to apply the correct diagnosis code for the condition. Even seasoned coders don’t always adhere to this guideline, especially if they have committed codes to memory.

Why is such a seemingly easy instruction considered a best practice? Every year, new ICD-10-CM codes become available, and with them comes a whole new set of instructions for their application. For example, code first, use additional code, and Excludes1 and Excludes2 notes are published at the beginning of each new heading in the ICD-10-CM book. These new instructions can apply to older codes as well.

If a coder is only using the Alphabetic Index to look up a code, it is easy to miss those added instructional notes. This may create a medical necessity or other denial, resulting in precious time and manpower lost as well as unnecessary delays in payment. It is wise to get into the habit of looking up codes in the Tabular List so as to capture any additional information necessary to properly apply a code to a claim.

Editor’s note: The full article was originally published on JustCoding. Stalter is the CDI manager for M*Modal in Pittsburgh. Contact her at crystal.stalter@mmodal.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.