HIMagine that: Guideline 19 revisited

February 6th, 2017 / By Donna Smith, RHIA, Sue Belley, RHIA

Donna: Hey Sue, have you read the WEDI document on the 2016 ICD-10-CM Clinical Indicators? This is another opinion on Guideline 19, which was published in the 2017 “ICD-10-CM Official Guidelines for Coding and Reporting.”

Sue: Yes, but it did not appear to provide any new solutions; it just identified additional coding guidance from groups such as the OIG and CMS/AHA guidance regarding ICD-10.

Donna: Well, as we discussed in an earlier blog, we don’t think that Guideline 19 indicates that the documentation should not be clarified. Instead, our opinion is that the clinical validity of physician documentation should be the responsibility of a clinical person such as the clinical documentation improvement specialist or physician.

Sue: Our fellow blogger Barbara Aubry has weighed in with an on this topic as well. My personal opinion squares with hers: Coders are not clinicians and should not be charged with clinical validation of a diagnosis recorded by a physician. It’s also outside their scope of practice to ask coders to reconcile the clinical data with a diagnosis.

Donna: Correct, but that does not mean that no one should question the provider in a case where a diagnosis does not seem to be clinically supported. I think that this responsibility lies directly on the shoulders of the clinical documentation improvement specialist.

Sue: I agree, but I think that hospitals should have a clear policy that details the process and identifies the departments that should be involved. Most of the hospitals I have dealt with have a Quality or Compliance department with an escalation policy that identifies the specific steps that should be taken to resolve unsupported documentation.

Donna: In addition to unsupported documentation, I think the policy should involve a process around copy/paste that identifies potential problems with that process as well. In reviewing records, some of the diagnoses that seem unsupported are actually copied from a previous document or a problem list.

Sue: Back in 2013, there were several studies indicating problems around copy/paste and the OIG made this a priority in the 2013 OIG Work Plan.

Donna: This year the OIG is focused on risk adjustment data that is coded and billed but potentially unsupported. The OIG states “CMS estimates that 9.5 percent of payments to MA organizations are improper, mainly due to unsupported diagnoses.”

Sue: It seems like hospitals would want to put top priority on establishing this policy and put a process in place to validate and request additional documentation for any diagnosis that appears unsupported in documentation in any setting.

Donna: Stay tuned for a new 3M webinar that’s coming up this month. I’ll be speaking about “Quality Checks on Physician Documentation,” which will address these issues and more!

Sue Belley, RHIA, Donna Smith, RHIA, are with the consulting services business of 3M Health Information Systems.