News: Workgroup clarifies clinical documentation in 2017 ICD-10 guidance

When coders can rely on the written diagnosis statement from a provider, it may negate all clinical documentation improvement efforts, according to an issue brief released by the Workgroup for Electronic Data Interchange (WEDI). In its 2017 Official Guidelines for Coding and Reporting, A. 19, CMS discussed code assignment and clinical criteria, specifically that the assignment of a diagnosis code should be based on the provider’s diagnostic statement that the condition exists. This Guideline, which has since been supported by the AHA’s Coding Clinic for ICD-10-CM/PCS, Third Quarter, has caused concern throughout the healthcare industry, especially in light of quality program reporting and auditing, WEDI says. The WEDI sought to clarify confusion regarding clinical documentation and ICD-10 coding.

Organizations should look at how they previously handled situations where there appears to be a disconnect between the physician’s diagnosis versus other clinical documentation, says WEDI. Where possible, querying the physician is advisable, both to validate the statement and to confirm why the documentation differs.

Click here to read the brief.