Q&A: Coding diagnoses without clinical criteria
Q: I was wondering how CDI programs are dealing with clinical validation of conditions as opposed to coding and the coding guidelines that instruct coders not to skip diagnoses just because of clinical criteria. What do you do when executive leadership says to just skip coding diagnoses rather than trying to gain clinical clarification? Has anyone else had this issue and can you offer advice?
Response #1: At our organization, our job aid with the coding department states that CDI specialists are to send clinical validation queries. If a CDI specialist is assigned to a case and the coder feels a clinical validation query is necessary, they send a notification to the assigned CDI specialist to send the clinical validation query. If a CDI specialist is not assigned to the case that needs a clinical validation query, coders send a notification to their CDI buddy. CDI specialists are assigned coding buddies, and the buddy system is updated yearly (or more if needed). The CDI and coding buddies also communicate for any case/coding questions. This process works very well for us.
Response #2: If a provider is documenting a condition and the clinical indicators are not aligned with the organizational definitions (we do have a process for organizational definitions, and we do not have many diagnoses that fall into this category), CDI specialists will send a clinical validation query. If the provider does not rule out the condition or provide additional clinical evidence, the condition would remain in the record (assuming it met Uniform Hospital Discharge Data Set requirements for capture). We use the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice brief to support our practice and would be sharing that information with senior leadership, explaining that this is a potential compliance issue.
Our coders reach out to the CDI department to send clinical validation queries or to determine if a condition is ruled out or in. I would argue that if it is documented and not supported it needs to be queried. According to the Official Guidelines for Coding and Reporting, the assignment is based on the documentation. I would try to share this information and discuss that coders are held to the guidelines:
19. Code assignment and clinical criteria
The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists. 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. If there is conflicting medical record documentation, query the provider.
Response #3: Our organization ran into this same issue. The Coding Clinic, Fourth Quarter 2017, p. 110, states it is not appropriate to develop internal policies to omit codes automatically when the documentation does not meet a particular clinical definition. We used this statement and showed it to our CDI physician advisor who then took this topic to leadership. They also discussed this issue with corporate compliance. This Coding Clinic was enough to change our practice at our institution. However, we still struggle with staff going back to old habits. Our process now is that any clinical validation query that is answered incorrectly gets escalated to our physician advisor team.
Response #4: At our organization, we have found opportunities to not code conditions that are not clinically supported, as there was no treatment or monitoring, because if it does not meet the definition of a reportable diagnosis then we should not be coding it anyways. This is not always the case, but it has helped prevent some clinical validation queries going back to the treatment team, as we shouldn’t be trying to code something that does not meet the definition of a reportable diagnosis.
Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council. For the purposes of this article, all Council member answers have been deidentified.