HCC Coders Find Surprises in Coding Clinic for ICD-10

HCC Coders Find Surprises in Coding Clinic for ICD-10

By Sheri Poe Bernard, CPC, COC, CPC-I, CCS-P

Risk adjustment (RA) coders are the best diagnostic coders out there, bar none. They know the importance of Guidelines and of Coding Clinic references. They use the Index effectively. They understand how crucial proper coding is to the financial livelihood and audit survival of the plans for whom they work. They are disciplined and they are smart.

So I really haven’t been worried about how RA coders will make the transition to ICD-10-CM coding. ICD conventions, logic, and organization are largely unchanged. Only the codes are new. ICD-9-CM diseases, which RA coders understand well, are the same diseases abstracted in ICD-10-CM.

Still, the devil is in the details when transitioning to anything new. And the devil some of us may need to wrestle to the ground for ICD-10-CM may be the AHA’s Coding Clinic for ICD-10.

CMS directs RA coders to follow the advice published in the American Hospital Association’s Coding Clinic for ICD-9, and in October, Coding Clinic for ICD-10. If you haven’t looked at Coding Clinic for ICD-10 to see how it is going to affect RA coding and your company’s RA policies and procedures, do it now, and read carefully. Coding Clinic for ICD-10 started as a tabula rasa – blank slate – and is building a whole new set of rules rather than building on the foundation of Coding Clinic for ICD-9.

For example, Coding Clinic for ICD-10, Q4 2013, discusses any assumed causal relationship between diabetes and osteomyelitis. Coding Clinic for ICD-9 states that a presumed relationship exists, meaning that any osteomyelitis in a diabetic patient can be considered a complication of diabetes, unless the provider states otherwise. This rule increases the payout for HCCs when the conditions coexist but are not linked in documentation.

Coding Clinic for ICD-10 reverses the Coding Clinic for ICD-9 rule:

ICD-10-CM does not presume a linkage between diabetes and osteomyelitis. The provider will need to document a linkage or relationship between the two conditions before it can be coded as such.

No presumed etiology and manifestation relationship! Until we hear otherwise, I would assume this change eliminates three other presumed causal relationships from Coding Clinics for ICD-9: diabetes and LOPS, diabetes and neuropathy, and diabetes and gangrene. This aligns with the information in the CMS RADV Submission Checklist:

Records submitted to validate HCCs that encompass additional manifestations or complications related to the disease … should include language from an acceptable physician specialist which establishes a causal link between the disease and the complication.

A large number of Coding Clinic for ICD-9 rules don’t roll over into Coding Clinic for ICD-10. Many rules that have been drilled into RA coders for years may no longer be valid in October. For example, Coding Clinic for ICD-9, Q3 2011, tells us to assign a code for dysthymic disorder when the provider documents “anxiety with depression” (but not “anxiety and depression”). We have no similar instruction in Coding Clinic for ICD-10. How will your organization code anxiety with depression in October? F34.1? F41.8? These codes map to different HCCs and RxHCCs.

When one thinks of how many internal coding decisions in risk adjustment are made based on Coding Clinic, one realizes we still have a way to go in our ICD-10-CM preparations. We can’t presume to code for ICD-10-CM using obsolete Coding Clinic rules, and we will need internal guidance for the many voids that will be created as ICD-9-CM retires. I imagine the folks in charge of writing internal RA coding policies—the ones that provide answers to coding questions that aren’t covered in the Guidelines or Coding Clinic—are sharpening their pencils and preparing for a long, hot summer.

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Sheri Poe Bernard

Sheri Poe Bernard

Sheri Poe Bernard, CPC, COC, CPC-I, CCS-P, has developed education, training, and referential medical coding and reimbursement products for 20 years. She is the author of the AMA's 2015 publication, Netter's Atlas of Surgical Anatomy for CPT Coding. Her areas of expertise include CPT, ICD-9-CM, ICD-10-CM, and risk adjustment coding.
Sheri Poe Bernard

About Has 5 Posts

Sheri Poe Bernard, CPC, COC, CPC-I, CCS-P, has developed education, training, and referential medical coding and reimbursement products for 20 years. She is the author of the AMA's 2015 publication, Netter's Atlas of Surgical Anatomy for CPT Coding. Her areas of expertise include CPT, ICD-9-CM, ICD-10-CM, and risk adjustment coding.

One Response to “HCC Coders Find Surprises in Coding Clinic for ICD-10”

  1. karen Echols says:

    Could I find out if there is any new rulings from CMS about the use of coding clinics for icd9 to roll over to use for icd10 coding.

    Thank you for any prompt response that you could offer. I am currently in an debate over this issue.

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