Guest Post: Minute for the medical staff, part 1

By James S. Kennedy, MD, CCS, CDIP

Those of us who care for critically ill patients intuitively know who will have a long hospital stay and who will die. As such, intensive care unit (ICU) scoring systems based on clinical indicators such as Acute Physiology and Chronic Health Evaluation Three (APACHE-3) or Simplified Acute Physiology Score Three (SAPS III) in adults or Pediatric Index of Mortality Two (PIM2) in children have been developed, though validity in an individual patient varies.

Medicare, state governments, and private enterprise, such as Vizient, Truven, Quantros, and 3M, also have scoring systems based on the ICD-10-CM codes derived from explicit, clear, and consistent provider documentation. As such, how we define and document diagnoses that predict morbidity and mortality is essential if we want our patient’s risk to be accurately portrayed.

Physician definitions and documentation are crucial

In navigating the ICD-10-CM maze, we must remember the following as written in the Coding Clinic for ICD-10-CM, Fourth Quarter, 2016:

• Code assignment is based only on provider documentation of a codeable condition, not on w a superbill definition or a clinical abstraction form of the medical record. Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis, can diagnose the patient.
• While physicians may use a particular clinical definition, or set of clinical criteria to establish a diagnosis, the ICD-10-CM code is based only on his/her documentation, not on clinical indicators supporting these definitions or indicators. In other words, regardless of whether a physician uses the new clinical criteria for sepsis (Sepsis-3), the old criteria (Sepsis-1 or Sepsis-2), 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.

• 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. As such, if the physician documents a condition that does not meet a facility’s definition, the physician may be approached to clarify whether he or she really thinks the patient has the documented condition. These queries are not a criticism of a physician’s judgment, but represent a request to be reassured that the diagnoses are based on the physician’s best medical judgment and that he or she will participate in any defense of codes based on documentation which may be subsequently denied.

Editor’s note: This article originally appeared in Revenue Cycle Advisor. Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at jkennedy@cdimd.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. To read the second part of this article, return to the blog next week.