When Official Coding Guidelines Could be Confusing

Do your physicians and ancillary staff know the ICD-10-CM coding rules?

Based on many years of personal experience, most physicians and ancillary staff who do not code really don’t know or understand the coding rules. 

This is not particularly surprising, because even the best coders are sometimes confused by the extensive Official Guidelines for Coding and Reporting and Coding Clinic instructions, which at times may seem to be in conflict. In fact, outside of professional coders and auditors, few subscribe to Coding Clinic. This issue becomes more complicated when some of the coding conventions may not be consistent with how a physician medically describes patients’ conditions, diseases, or symptoms.

As one example, the official guidelines state the following, specific to relying upon ancillary staff information for code assignment: “code assignment is based on the documentation by the patient’s provider (i.e., physician or other qualified healthcare practitioners legally accountable for establishing the patient’s diagnosis…)”. This guideline goes on to explain certain types of measurements, such as body mass index, coma scale, stroke scale, social information, etc., all of which may be documented by ancillary staff. However, the associated diagnosis, such as obesity, acute stroke, etc., must be documented by the provider. 

A common discrepancy finding involves emergency department cases. Although the hospital coding abstraction is based on the complete medical record documentation by the treating provider(s), independent radiology groups that outsource coding typically provide the radiology report (and maybe the orders) to their coders. Some coders can also access the emergency department record, but many cannot.

The struggle these coders may have is determining whether the order is a mechanism of injury only (i.e., fall, MVA, etc.). However, the radiology report has specific signs or symptoms, such as injury left shoulder, chest pain, etc. When digging into the details on audit, these indications are tech notes produced from discussion with the patient, but they are not documented in any treating provider’s record. In one large hospital system, orders were entered by clerical staff based on registration information or the emergency department protocols. When queried by radiology department staff, they were informed that no physician had evaluated the patient at the time the orders were placed. In some cases, there are obvious contradictions between the provider’s medical documentation and the information that populates reports. 

Another scenario that is common in some practices is to verify the orders and report covered diagnoses. If they do not, staff then query the patient and add additional information that is not documented by the treating provider(s) in order to achieve compliance with coverage policies.

As a nurse or ancillary staff member, the standard of care is to interview the patient. Nursing care plans that address identified problems are expected. Information gleaned from discussion and querying the patient can provide critically important information to the treating provider. Patient statements and information can change (and even conflict) during the same visit. In the real clinical world, it would be egregious to omit these steps and/or ignore information stated by the patient. 

Because it is doubtful that many providers and staff know all the ICD-10-CM official guidelines, this disconnect between common clinical practice standards and coding rules is something that should be addressed as part of effective compliance programs. Education and ensuring that both providers and staff understand the coding rules regarding what documentation can be used to establish diagnoses is recommended.