Clinical Validation

We recently celebrated the one year anniversary effective date of Official Guideline I.A.19 “Code Assignment and Clinical Criteria.” Let’s take a trip down memory lane:

“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 based on clinical criteria used by the provider to establish the diagnosis.”

ICD-10-CM/PCS Coding Clinic®, Fourth Quarter ICD-10 2016 Pages: 147-149 further addresses the topic of code assignment and clinical criteria. The content in Guideline I.A.19 is not a new concept. The guideline reaffirms the long standing principle that coding should be ultimately based on provider’s documentation. Furthermore, coders should not exclude coding a reportable diagnosis that is documented by a provider based solely on the coder’s interpretation of clinical indicators or a perceived lack thereof. Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis, can “diagnose” the patient.

We must remember that clinical validation is somewhat subjective and providers do not always agree on how to define conditions. The provider is responsible for choosing the criteria used to establish a diagnosis, not the coding professional or CDS. Under-coding is not playing it safe; it can be viewed as a misrepresentation of services with compliance risks attached. Both over-coding and under-coding are enemies of data integrity.

So, what is a coder to do? We must exercise common sense in the execution of our role and continue to appropriately rely upon the clinical validation process and/or query process to help ensure good documentation and correct coding.

Additionally, the AHIMA practice brief “Clinical Validation:  The Next Level of CDI” does a good job describing the distinction between coding and clinical validation and should be referenced by all stakeholders.

Clearly, I.A.19 does not erase the importance of the UHDDS Guidelines nor does it negate the advice as outlined in the 2016 AHIMA Practice Brief on compliant queries. First and foremost, I.A.19 does not exist in a silo; it must be viewed through the lens of all guidelines and coding conventions. Secondly, I.A.19 reminds the coding professional of the fact that the assignment of a diagnosis code is ultimately based on the provider’s diagnostic statement that the condition exists, although we must continue to perform our due diligence as coders to dialogue with Clinical Documentation Improvement professionals and create compliant queries as warranted.

The coding professional should not put themselves in a position to exclude coding a reportable diagnosis that is documented by a licensed provider based solely upon the coder’s interpretation of clinical indicators. Naturally, UHDDS reporting criteria are integral to correct code assignment.

So, talk to me. What are your thoughts on the past year of living with this guideline?

Daniel Land, RHIA, CCS

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