The 2018 fiscal year was accompanied by updates to the ICD-10 codes again. These changes included 360 new codes, 142 deleted codes, and 226 revised codes. Of course, certain diagnoses were impacted more than others. For example, there are 72 new codes just to better describe non-pressure ulcers while nine new codes are specific to heart failure. However, it is not only critical to be knowledgeable about these ICD-10 code changes, but also to follow coding guidelines. In this series on 2018 ICD-10 codes, we will first provide a coding refresher and then follow-up with additional blogs that review the codes as they relate to specific diagnoses.
Guidelines vs. Classification Instructions / Conventions
The guidelines are defined as a set of rules that were developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. They have been approved by the four organizations that make up the cooperating parties for the ICD-10-CM, which include the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the CMS (Centers for Medicare and Medicaid Services), and the NCHS (National Center for Health Statistics). These guidelines were created to assist the healthcare provider and the coder to determine diagnoses.
However, the instructions and conventions of the classification take precedence over the guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, which incorporate conventions, but also provide additional information.
Achieving Accurate Coding
Consistent, complete documentation is critical because without it accurate coding cannot be achieved. However, this is only attainable if there is a joint effort between the healthcare provider and the coder. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated. There must be consistency and complete documentation in the medical record. If coding is incorrect or not supported by the medical record the entire episode of care is at risk of nonpayment or take back!
Now let’s move onto assigning the proper codes. An assigned diagnosis code is based upon the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has the condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. This becomes the primary diagnosis, which is the condition or problem/reason for home care and chiefly responsible for the services provided.
However, any additional diagnoses for conditions managed during the episode should be included in the medical record too. If more than one diagnosis is treated choose the one that is most acute or requires the most intensive services. Any secondary diagnoses must be relevant to the care rendered or affect the patient’s responsiveness to treatment or rehab, even if it is not the focus of the home health POC.
Any diagnosis listed must be documented in the POC as well as the OASIS. A chronic condition always will impact the POC; therefore, it is particularly critical that it is coded and addressed in the POC. The Primary Dx on the POC, UB-04 and the OASIS must match. Codes that need to be included, but do not fit in M1023 can be reported on the POC in the narrative section. For further guidance on these three forms (OASIS, POC and UB-40), please visit the Medicare Claims Processing Manual instructions for FL 67 and 67 a-q.
Dealing with Certain Words
There are certain key words used in coding such as “with” or “in” that need to be interpreted correctly. When these words appear in a code title, the Alphabetic Index, or an instructional note in the Tabular List, they should be interpreted to mean “associated with” or “due to”. The classification presumes a causal relationship between the conditions linked by these terms in the Alphabetic Index or Tabular List. Any of the conditions listed under the “with” sub-term can be coded without the physician stating that these conditions are linked, unless another guideline states there must be a documented linkage between the two diagnoses. An example would be sepsis and organ failure that is not clearly stated as due to sepsis.
Correct coding can be a daunting task. Whether you are looking to outsource your coding or require coding assistance, the 5 Star team is here to help. We have a highly skilled staff of certified, experienced RN coders who can take care of your coding needs, working with your clinicians to ensure accuracy, clinical compliance and optimized reimbursement. For further information on our coding services and training options, please contact us at [email protected] or 866-428-4040.