Note from the Advisory Board: All professional backgrounds welcome

by Karen Newhouser, RN, BSN, CCDS, CCS, CCM, CDIP

I have been pondering the clinical validation conundrum with the publication of the AHA Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2016, as well as a practice brief published in the August 2016 edition of the Journal of AHIMA, “Clinical Validation: The Next Level of CDI.” When CMS and the National Center for Health Statistics published the 2017 Official Guidelines for Coding and Reporting, in August, they included a new convention, I.A.19, which notes that the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists; the guidelines further note that the provider’s statement attesting the patient has a particular  condition is sufficient. Code assignment, according to this new convention, should not be based on the clinical criteria that the provider used to establish his or her diagnosis.

Carrying this thought forward, the convention tells us that although we should use clinical criteria to identify query opportunities as well as to identify diagnoses that may or may not be present, we must understand that the provider is the only one who can determine the presence or absence of a diagnosis.