Q&A: Defining a coder’s role in clinical validation

Q: Why is clinical validation needed if the ICD-10-CM coding guidelines state that the provider’s statement is sufficient for code assignment?

A: The ICD-10-CM Official Guidelines for Coding and Reporting, Section 1.A.19, state:

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.

This emphasizes that code assignment is based on provider documentation.

The ICD-10-CM guidelines also state:

A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized.

While it is the primary responsibility of the provider to ensure accurate and appropriate documentation, coders and CDI specialists are responsible for working with providers to improve their documentation.

Clinical validation, or assessing documentation to determine whether reported diagnoses are supported, is necessary to prevent denials. Billing requirements are governed by CMS and the False Claims Act, and go beyond what’s outlined in the ICD-10-CM guidelines.

Editor’s note: This article originally appeared in JustCoding. This question was answered by Courtney Crozier, MA, RHIA, CCS, CDIP, clinical development analyst at 3M, during the HCPro webinar, “Navigate ICD-10-CM Coding and Documentation Challenges for Malnutrition.”