Industry hot topics: Insight into ambiguous, inconsistent, conflicting advice and guidance

Every month, you will find a new topic or question along with the committee’s findings posted to this page and publicized in CDI Strategies.

Topics under review for future release include:

  • Hierarchy
  • Sepsis
Topic Summary Discussion point Date posted
Comparative/ contrasting secondary conditions

The 1998 Coding Clinic instructs not to code comparative/contrasting secondary conditions as this guideline “is only for the selection of the principal diagnosis.” The 2016 Coding Clinic instructs to code these conditions if noted at the time of discharge. The current 2020 Official Guidelines for Coding and Reporting still only include specific comparative or contrasting instruction in Section II, Selection of Principal Diagnosis. Section III.C instructs to code uncertain diagnoses when documented at the time of discharge. 

Establish if both guidelines refer to all diagnoses (principal and secondary), making it appropriate to code all uncertain conditions documented at the time of discharge (the latest documentation in the stay).

Pancytopenia with febrile neutropenia A 2014 Coding Clinic says that "NCHS has agreed to address the issue of the excludes1 at category D61 at a future ICD-10-CM Coordination and Maintenance Committee (C&M) meeting". No further Coding Clinic has addressed this topic. However, the ICD-10 Official Guidelines for Coding and Reporting were published in 2015 with an Excludes 1 note exception that still stands today: “An exception to the Excludes 1 definition is the circumstance when the two conditions are unrelated to each other.”  Determine in what circumstances queries will be generated to clarify if these conditions have separate etiologies and therefore would be appropriate to code separately. Educate using this documentation tip if needed. 4/21/2020

Arteriovenous malformation (AVM)

The ICD-9 and ICD-10 indexes have led/lead to a congenital nature but Coding Clinic, third quarter 2018, p. 21, instructs to code as acquired based on research. Establish at what point in time the hierarchy rule will be followed if the index and/or guideline has not been updated. 5/1/2020
Gangrene in diabetes 

I96 (gangrene, not elsewhere classified [NEC]) has an Excludes 2 note: Gangrene in diabetes (E08-E13 with .52).

There is a sub-term in the Alphabetic Index of ICD-10 under “gangrene” that states “gangrene>with diabetes.” It instructs the coder to “see diabetes, gangrene.” Based on The Official Guidelines for Coding and Reporting, the coder needs to code to the greatest level of specificity, so the coder is not able to stop at I96 but rather needs to go to the specified sub-term. When going to diabetes>gangrene as the Index instructs, the coder gets E11.52. There are no instructions under E11.52 stating to use an additional code for the gangrene.

ICD-10-CM Guideline I.B.9 states to “Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis.” In this case, the E11.52 clearly identifies all diagnoses present.

ICD-10-CM Guideline I.A.12.b states, “When an Excludes 2 note appears under a code, it is acceptable to use both the code and the excluded code together, 'when appropriate.' "

Establish when coding I96 (CC) (gangrene, NEC) with E11.52 (type II diabetes mellitus with gangrene) would be appropriate. If unsure, pose the question to the American Hospital Association (free of charge) at: 6/15/2020
Congenital conditions ICD-10-CM Official Guidelines for Coding and Reporting, I.C.17 states “Whenever the condition is diagnosed by the provider, it is appropriate to assign a code from codes Q00-Q99.” Some assume that reportable criteria is required (as stated in Guideline III), while others interpret this to mean that anytime a congenital condition is documented (and not completely corrected with past surgery), it should be coded. 

(Refer to the American Hospital Association's (AHA) Coding Clinic, first quarter 2013, p. 14: Sacral nevus on a newborn)

To avoid inconsistent data and the risk of denials, request that the National Center for Health Statistics revise Guideline I.C.17 to clarify that it is an exception to Section III. A possible clarification suggestion is:  Whenever the condition is diagnosed by the provider, it is appropriate to assign a code from codes Q00-Q99, regardless of the absence of reportable criteria or patient age.  

Requests may be e-mailed to:

Questions/comments may also be sent to CMS: