Guideline I.A.15: The One that Makes  Risk Adjustment Coders Happy

Guideline I.A.15: The One that Makes  Risk Adjustment Coders Happy

Providers no longer need to link documentation to diabetes mellitus for certain related conditions for coding; it’s implied.

Medicare risk adjustment (MRA) coders identify active diagnoses that determine a patient’s level of risk (the likelihood of that patient needing medical care). This helps health plans project the cost of caring for their patient population. That is why good MRA coders always take time to read all patient reports (lab, imaging, biopsy, hospital discharge) to capture new diagnoses.

MRA coders rely on providers to report all relevant, present diagnoses in their patients. Failure to do so will skew the patient profile and negatively affect care.

The best tools at an MRA coder’s disposal are:

  • Being aware of current ICD-10 guidelines;
  • Taking time to read reports in the chart; and
  • Always querying the provider when documentation is unclear.

In the past, MRA coders could not assume a cause-and-effect relationship between conditions when these relationships were not clearly documented in the medical records. MRA coders had to ask the provider whether two conditions (such as diabetes mellitus (DM) and polyneuropathy or DM and peripheral vascular disease (PVD)) were linked.

Now, thanks to ICD-10-CM Guideline I.A.15, there is less ambiguity. According to the guideline, “The word ‘with’ or ‘in’ should be interpreted as ‘associated with’ or ‘due to’ when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instrumental note in the Tabular List.”

The guideline further states, “These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated or when another guideline exists that specially requires a documented linkage between two conditions.”

That means MRA coders no longer have to ask providers to link DM to:

  • Cataract (E11.36 Type 2 diabetes mellitus with diabetic cataract)
  • Chronic kidney disease (E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease)
  • Foot ulcer (E11.621 Type 2 diabetes mellitus with foot ulcer)
  • Gastroparesis (E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy)
  • Polyneuropathy (E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy)
  • PVD/Atherosclerosis of lower extremity (E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene)
  • Retinopathy (E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema)

When these conditions are documented, you can automatically link them to DM. For example, if in the assessment the physician reports as final diagnoses:

  • DM type 2
  • Cataract

The correct code is E11.36.

But if the final diagnoses are:

  • DM type 2
  • Cataract due to radiation (not secondary to DM)

The correct codes are E11.9 Type 2 diabetes mellitus without complications and H26.8 Other specified cataract.

In a second example, if in the assessment the physician reports as final diagnoses:

  • DM type 1
  • Dermatitis

The correct code is E10.620 Type 1 diabetes mellitus with diabetic dermatitis.

But if the final diagnoses are:

  • DM type 1
  • Dermatitis due to detergents (not secondary to DM)

The correct codes are E10.9 Type 1 diabetes mellitus without complications and L24.0 Irritant contact dermatitis due to detergents.

As you can see, Guideline I.A.15 empowers coders to make certain diagnosis coding decisions without having to query the provider.

Yves-Edouard Baron

Yves-Edouard Baron, CPC, CPMA, CRC, CDEO, was born in Haiti, where he worked in the medical field. Baron’s medical background made him a perfect candidate to review medical records, looking for hidden or unreported diagnoses and interpreting lab results. He now works as an MRA auditor. Baron is a member of the Weston, Fla., local chapter.

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