ICD 10 coding guidelines clarification

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Hello all,
I recently ran into a situation in which I would like some other's input on the coding guidelines. In regards to inpatient coding, when looking at the ICD 10 rules you still have the same additional diagnoses (AD) guideline - not going to reiterate it for the sake of this post though. However, there is a new rule that states:
"19. Code assignment and Clinical Criteria
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis."

The way I'm interpreting this is it is conflicting in regards to the AD guideline that says (and I'm surmising here not using the guideline verbatim) that the diagnosis must be treated, monitored, etc., in order for it to be coded as if it existed. However, with this new guideline I'm confused on the fact that now the provider only saying this patient has X diagnosis, it should be coded as if it existed? What if it wasn't treated/monitored/etc.? Do you still have to code as if it existed? The specific scenario that comes to mind is sepsis: say the physician does not document the patient has sepsis, but is queried and the physician states yes had sepsis POA. There is no indication that this required treatment, monitoring, etc., but under this rule would still have to be coded as if it existed? What about specifics such as gram-negative PNA. If a query states GN PNA but there are no cultures or notation of GN PNA in the documentation other than the query, should it still be coded as if it existed, just because the physician stated (again, supposing it didn't meet AD guidelines). It doesn't even have to be something that specific, those were just the top of my head.

Could anyone give me some clarification on when to follow the AD guideline, and when to take into consideration this code assignment and clinical criteria rule? As the AD guideline, I just don't see the physician stating a dx as information enough in order for a condition to qualify for reporting on the inpatient claim if it doesn't meet AD criteria. Will they do a coding clinic or some sort of guidance to clear up the conflicting rules in regards to this?
Thank you in advance!
 

CodingKing

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The guideline is really just stating you can't assume the diagnosis based off medical criteria. You know since a coder can't diagnose a patient. Say you know the patient is morbidly obese based off a BMI, you can't code as morbidly obese unless the physician documents it as such.

Its not saying you need to report every diagnosis mentioned in the record. that would still follow the "diagnosis must be treated, monitored, etc., in order for it to be coded" rule.
 
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barbarat

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ICD 10 coding guideline clarification

I can understand the confusion, and I'm interpreting your question - I think - in the true spirit of it. The newer guideline applies also to scenarios like an HIV diagnosis. It states (and I'm summarizing) that I don't have to see proof of a positive test for HIV in the documentation - if the Provider states this patient has HIV, then I am to code it without any further proof. As coders, we are not allowed to "chase" lab or test results outside the current progress note, thus it does make sense to me that the Provider's written statement of fact is sufficient, whether it's for HIV, sepsis, or anything other disease/condition that is not verified by test results or treatment in the progress note.

But then, any of us could be wrong on any given day. :)
 
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