Guidelines? What Guidelines?

Make it known: Guidelines drive coding, compliance, reimbursement, and quality of healthcare.

By Ken Camilleis, CPC, CPC-I, CMRS, CCS-P

You rely heavily on a variety of guidelines to assist in your work as a coder. Guidelines come from ICD-9-CM and ICD-10-CM, CPT®, payers, government agencies, and a host of other sources. There is no “one size fits all” with regard to payer guidelines and related protocols (e.g., Which payers still accept consultation codes; and for those who don’t, which crosswalk codes should be used?)—not to mention that such rules are constantly changing.

Thankfully, the standard coding reference books (ICD-9/10, CPT®, and HCPCS Level II) serve as a starting point for proper and optimal coding. Physicians and data processors also need to understand these guidelines because they not only drive coding, but also compliance, reimbursement, and quality of healthcare. My personal experience suggests, however, that the medical community outside of the coding world often lacks knowledge regarding coding guidelines.

Guidelines Aren’t Common Knowledge

For example, I was once assigned to an evaluation and management (E/M) auditing job, which involved validation of pre-coded SOAP (subjective, objective, assessment, and plan) and narrative clinical notes. At first, there seemed to be no methodology to determining the level of the office visits. I asked my supervisor if her input staff were using the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services. She looked at me like I had two heads and said, “This is 20xx, why would we be working with 1997 guidelines?”

She had no idea what I was talking about. As a result, I had to go through the painstaking process of validating (and invalidating) all of their codes by scoring the history of present illness, review of systems, etc., for each service. Needless to say, the E/M levels I came up with were, in many cases, different from what they had initially coded.

In another instance, I was interviewing with a physician regarding clinical documentation improvement (CDI), and mentioned the “official guidelines.” You and I know that I was referring to the Official ICD-9-CM Guidelines for Coding and Reporting near the beginning of the ICD-9-CM codebook. After the third time I said “guidelines,” the doctor interrupted and asked, “Ken, can you explain what ‘guidelines’ you’re referring to?” I pulled out an ICD-9-CM codebook and pointed them out to him. He had no idea these official guidelines even existed. He only worked from the body of the book to find codes in the Alphabetic Index and the Tabular List.

Spread the Word

As a coder, you understand that guidelines are your friends. You know from experience that there’s more to proper coding than simply looking up codes in an index or list. Aside from the 1995 and 1997 Documentation Guidelines to Evaluation and Management Services, plus the instruction at the beginning of each section in CPT® (anesthesia, surgery, etc.), there are additional guidelines sprinkled throughout your codebooks.

Instructional notes, conventions, symbols, and notations are key to optimal coding. For instance, a knee surgeon who performs an arthroscopic medial meniscectomy and resection of pathological plica at the same time may expect to be paid for both services. After all, there are CPT® codes for both procedures: 29881 Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed for the meniscectomy and 29875 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure) for the plica removal. However, a knowledgeable coder will note the words “separate procedure” at the end of the descriptor for 29875, which means the service is included as part of the global charge for the meniscus removal and not paid separately, unless performed contralaterally.

The chapter-specific coding guidelines in section I, subsection C of the Official ICD-9-CM Guidelines for Coding and Reporting, provide a wealth of information to which doctors and health information management specialists should be privy to. Many of these guidelines contain decision-tree type logic that results in deeper levels of nesting of information. This can be confusing, even for seasoned coders, because of the sheer amount of information imparted. As you become more experienced, however, you begin to spot coding patterns that don’t conform to guidelines—for example, incorrect linkage or sequencing of diabetes and related manifestation codes, hypertension, HIV, sepsis, diseases as cause of symptoms, and unbundling of services identified by CPT® codes.

With ICD-10 looming, you’ll soon be faced with a completely new set of guidelines. Although the Official ICD-9-CM Guidelines for Coding and Reporting are an excellent foundation, there will be new algorithms in the form of the instructional notes that will appear throughout the ICD-10-CM codebook. The Excludes notes from ICD-9-CM are a good example of this: In ICD-10-CM, you’ll have two distinct types of exclusion notes, Excludes1 and Excludes2, which are both logic-based. There are also notes indicating the need to extend a code out to seven characters, with the appropriate choice for the seventh character. Both like and unlike ICD-9-CM, there are a host of other conventions and notations in ICD-10-CM with which you’ll need to become familiar.

Drive It Home

Your role as an educator is crucial to compliance and reimbursement. Take each day that goes by in 2014 as an opportunity to educate your providers to specify key information so everyone in your practice is on the same page.

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Ken Camilleis, CPC, CPC-I, CMRS, CCS-P, is an educational consultant and PMCC instructor with Superbill Consulting Services, LLC. He is also a professional coder for Signature Healthcare, a health system covering much of southeastern Massachusetts. Camilleis is the 2014 education officer for the Quincy Bay Coders, Quincy, Mass.

Michelle Dick
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Michelle Dick

Executive Editor at AAPC
Michelle A. Dick has been executive editor for AAPC for over seven years. Prior to her work at AAPC, she was editor-in-chief at Eli Research and Element K Journals, and disk ad coordinator, web designer/developer, and graphic artist at White Directory Publishers, Inc. Dick has a Bachelor of Science in Graphic Design from the State University of New York - Buffalo State and is a member of the Flower City Professional Coders in Rochester, N.Y.
Michelle Dick
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Michelle A. Dick has been executive editor for AAPC for over seven years. Prior to her work at AAPC, she was editor-in-chief at Eli Research and Element K Journals, and disk ad coordinator, web designer/developer, and graphic artist at White Directory Publishers, Inc. Dick has a Bachelor of Science in Graphic Design from the State University of New York - Buffalo State and is a member of the Flower City Professional Coders in Rochester, N.Y.

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