Guest Post: Finding coding compliance at a crossroads, part 4

by James S. Kennedy, MD, CCS, CDIP

Note: This post is part four of four, excerpted from an article originally published in JustCoding. Read the first installment published on November 15. Click here to read the original.

In earlier posts, we discussed the evolution of the definition of sepsis and its implications in clinical care (Sepsis-1, Sepsis-2, and Sepsis-3), quality measurement (CMS’s SEP-1 core measure), and ICD-10-CM coding compliance.

We emphasized that the February 2016 definition of sepsis (Sepsis-3) as a “life-threatening organ dysfunction caused by a dysregulated host response to infection,” differed from the terminology of sepsis and severe sepsis that has been embraced by many clinicians, CMS, and ICD-10-CM. We also discussed how provider documentation using the Sepsis-3 terminology eliminates the term “severe sepsis,” and discussed that the definition change affected ICD-10-CM code assignment and compliance.

(Definitions and clinical indicators in Sepsis-2 are available here, and definitions for Sepsis-3 are available here. CMS’s definition of sepsis and severe sepsis for the SEP-1 core measure is available here. Please familiarize yourselves with these differing definitions.)

Coding Clinic update

Effective September 23, the American Hospital Association (AHA) Coding Clinic for ICD-10-CM/PCS published advice concerning the documentation and coding of sepsis in light of Sepsis-3. In Coding Clinic, Third Quarter 2016, p. 8, they stated “coders should never assign a code for sepsis based on clinical definition or criteria or clinical signs alone. Code assignment should be based strictly on physician documentation (regardless of the clinical criteria the physician used to arrive at that diagnosis).”

Coding Clinic went on to write (emphasis mine):

The coding guidelines are based on the classification as it exists today. Therefore, continue to code sepsis, severe sepsis, and septic shock using the most current version of the ICD-10-CM classification and the ICD-10-CM Official Guidelines for Coding and Reporting, not clinical criteria.

In my opinion, this means that if the diagnosis is incorporated by the documenting physician, Coding Clinic is saying ICD-10-CM still embraces the coding of:

• infections without sepsis
• with sepsis but without organ dysfunction
• with sepsis resulting in organ dysfunctions (otherwise known as severe sepsis)

The AHA further stated that if a physician arrives at a diagnosis of sepsis or severe sepsis using whatever criteria he or she wishes, and then documents these terms in the medical record, the coder is to code it, period, end of story.

Alternatively, while Sepsis-3 states that the word “sepsis” requires the presence of acute organ dysfunction, Coding Clinic states that ICD-10-CM does not recognize this clinical concept. Unless the provider documents “severe sepsis” or associates an acute organ dysfunction to sepsis, a code reflecting this concept, R65.20 (severe sepsis), cannot be assigned. Furthermore, if a provider wishes to diagnose and document the term “sepsis” (without organ dysfunction) using Sepsis-2 or other reasonable criteria, the coder is obligated to code it as such in ICD-10-CM.

Coding Clinic, Fourth Quarter 2016          

As we discussed in previous ACDIS Blog posts, the fiscal year 2017 ICD-10-CM Official Guidelines were amended to state (emphasis mine):

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.

In explaining this new guideline, Coding Clinic, Fourth Quarter 2016, pp. 147-149 stated (emphasis mine):

While physicians may use a particular clinical definition or set of clinical criteria to establish a diagnosis, the code is based on his/her documentation, not on a particular clinical definition or criteria. In other words, regardless of whether a physician uses the new clinical criteria for sepsis, the old criteria, his personal clinical judgment, or something else to decide a patient has sepsis (and document it as such), the code for sepsis is the same—as long as sepsis is documented, regardless of how the diagnosis was arrived at, the code for sepsis can be assigned. Coders should not be disregarding physician documentation and deciding on their own, based on clinical criteria, abnormal test results, etc., whether or not a condition should be coded.

Coding Clinic went on to highlight that this concept applies only to coding, not the clinical validation that occurs prior to coding. Coding Clinic emphasized that clinical validation is a separate function from the coding process and the clinical skill embraced by CMS and cited in the AHIMA practice brief Clinical Validation: The Next Level of CDI.

Coding Clinic then went on to say that (emphasis mine):

“a facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system.”

While I agree that facilities should standardize clinical definitions for clinical and coding validation purposes, note how Coding Clinic gave tremendous power to a payer to define any clinical term any way they want to. This may differ from that of a duly-licensed physician charged with direct face-to-face patient care responsibilities using the definitions of clinical terms he or she learned in medical school or read in their literature.

As such, while our facilities may implement clinical validation prior to ICD-10-CM code assignment, a payer that is not licensed to practice medicine and has no responsibilities for direct patient care, can require a provider or facility to use a completely different clinical definition that serves only one purpose in my mind, and that is to reduce or eliminate payment for care that was properly rendered, diagnosed, documented, and coded.

I’m sure that legal battles will ensue, given this caveat written by Coding Clinic.

Editor’s note: This post is an excerpt from an article originally published in JustCoding. Click here to read the full version. Kennedy is the president of CDIMD-Physician Champions, a Nashville-based group of physicians, coders, and clinicians engaged nationwide as CDI physician advisors, ICD-10 medical informaticists, and DRG and HCC compliance advocates. His opinions do not necessarily reflect those of ACDIS or its Advisory Board.