Update Facility-Specific Coding Guidelines – Part 2

Last week I started a series on developing facility-specific coding guidelines. This series is based on an AHIMA practice brief by the same name. This practice brief was updated in December 2023. Your assignment last week was to talk to other departments and understand their data needs as well as understanding what procedure codes will be assigned by the coders.

Today, document in your guidelines how many diagnosis and procedure codes are the limit for coding. Another way to say this is what is the maximum number of codes that can be assigned. You may need to consider if there are limitations by patient type – acute care inpatient, outpatient surgery, emergency department, skilled nursing facility, observation, etc.

Continuing with a procedure theme, do you use the X-modifiers on outpatient surgery cases? Do you use them for specific payers? Another procedure topic is the assignment of ICD-10-PCS codes on outpatient cases. Does your state require them or not?

Document the use of unlisted CPT codes or inpatient-only CPT codes. Are there additional steps to be followed when these codes are assigned?

Your guidelines should also specify which provider types may perform procedures – chiropractors, physician assistants, nurse practitioners, midwives, podiatrists, dentists, etc. Document where the coder will find bedside procedures; blood transfusions; dialysis; obstetric procedures; etc.

Let us review some specific procedures:

• Computer/robotic procedures – if the robotic portion is not part of the code description, does the coder assign another code? Would the coder assign S2900, or would that portion come from the chargemaster? Is the rule the same for inpatient and outpatient?

• Interventional Radiology/Cardiology – Do inpatient coders assign both the radiology and surgery portion for interventional surgery? Do the outpatient coders only assign the surgery portion?

• Radiology Procedures – Do you assign codes for x-rays, CT, MRI, Nuclear Medicine, PET scans, and ultrasounds? Are the expectations different for inpatient and outpatient?

• Neurology Procedures (EEG, video-monitoring, intra-operative monitoring, EMGs) – which of these procedures, if any, do you assign codes to? Are there differences based on patient type?

• Oncology Procedures – Are chemotherapy and radiation therapy coded? Are the rules different by patient type? How do you capture infusions and injections by patient type? Also consider midline, arterial line, PICC catheter insertions.

• Rehabilitation Procedures – Do any of the payer contracts pay by rehabilitation DRGs? If so, you need to assign at least one physical therapy or occupational therapy procedure code for inpatients.

• Newborn Procedures – hearing tests, circumcisions, vaccinations, etc. Do you capture any of these procedures?

• Pregnancy/Delivery Procedures – insertion of epidural catheter, artificial rupture of membranes, labor induction, fetal monitoring, etc. Are you coding any of these procedures?

Other procedures to consider include osteopathic manipulation therapy (OMT), chiropractic, detoxification, counseling, transfusions, CPR, and dialysis). Do you capture only the first procedure when multiple are performed, such as dialysis?

As you are writing your guidelines, create a column to document the reasoning for capturing the codes. For example, we capture midline catheters because the chargemaster is expecting a code on inpatients. Another reason could be that certain departments require the data.

This process is worth the time and effort because it helps to make the data consistent. It will also assist when training new coders.

Resources:

https://bok.ahima.org/topics/clinical-documentation-integrity/developing-facility-specific-coding-guidelines-2023-update