Coding Clinic 2023: A Comprehensive Review

Coding Guidelines Refresher

The Coding Clinic guidelines mandate accurate and compliant coding practices under the Health Insurance Portability and Accountability Act (HIPAA). These criteria ensure consistent and complete documentation in medical records, essential for accurate assignments. Without such documentation, accurate coding becomes unattainable, potentially leading to billing, reimbursement, and patient care management errors.

Understanding the four coding guideline sections is essential for compliant practices in healthcare settings:

• • Section I encompasses the fundamental structure, conventions, and general guidelines applicable to the entire ICD-10-CM classification, and chapter-specific guidelines corresponding to the classification’s chapters. 

• Section II provides guidelines for selecting principal diagnoses in non-outpatient settings.

• • Section III offers guidance on reporting additional diagnoses in non-outpatient settings.
• Section IV outlines outpatient coding and reporting procedures.

Sections I and IV apply to physician office coding guidelines. 

Section I

Section I includes an overview of the classification structure and its conventions, offering general requirements applicable to the entirety of the classification. It provides detailed chapter-specific guidelines that correspond with the arrangement of the chapters within the classification system.

Section II

Section II focuses on selecting a principal diagnosis, a process governed by the specific inpatient admission circumstances. Coding conventions outlined in the ICD-10-CM, including the Tabular List and Alphabetic Index, precede official coding guidelines in determining the principal diagnosis.

Either condition may take priority in sequencing when two or more related conditions could qualify as the principal diagnosis. However, this sequencing is subject to factors including:

• Circumstances of admission
• Provided therapy
• References within the Tabular List or Alphabetic Index

Section III

Section III outlines the rules for reporting additional diagnoses in non-outpatient settings, including:

• Acute care
• Short-term care
• Long-term care
• Psychiatric hospitals
• Home health agencies
• Rehab facilities
• Nursing homes
• Hospice services at all levels of care

Providers must designate “other diagnoses” when the Alphabetic Index or Tabular List in ICD-10-CM does not offer specific guidance. The responsibility for listing the following diagnoses in the patient record lies with the provider:

• Previous conditions
• Abnormal findings
• Uncertain diagnosis

Compliant Queries

Care providers must list diagnoses in their patient records. Regardless of credential, role, title, use of technology, or organizational objectives, all healthcare professionals seeking to clarify provider documentation must follow compliant query guidelines. 

To validate a diagnosis, the Centers for Medicare & Medicaid Services (CMS) requires clinical evidence in the medical record to support code assignment. It’s necessary for medical record entries to: 

• Be complete. 
• Support the diagnosis/condition.
• Justify the care, treatment, and services.
• Document the course and results of care, treatment, and services.
• Promote continuity of care among providers.

Section IV

​​Section IV offers guidelines for coding procedures and diagnoses relevant to outpatient settings, ensuring accurate and compliant coding practices for healthcare providers.

Common Coding Errors

Precise medical coding is essential for ensuring proper reimbursement, maintaining regulatory compliance, and promoting quality patient care. Below are common coding errors and ways to ensure accuracy for certain diagnoses.

Secondary Diagnoses Commonly Denied IP

A standard error in medical coding occurs when assignments lack support from established guidelines or accompanying documentation. This error can lead to claim denials and reimbursement delays. Among the most frequently denied diagnoses are:

• Encephalopathy
• Acute Respiratory Failure
• Acute Kidney Injury
• Malnutrition
• Sepsis
• Hyponatremia
• Acidosis
• Type II Myocardial Infarction

Diagnoses Commonly Reported with “Unspecified” Codes

Commonly reported diagnoses with “unspecified” codes include:

• Alzheimer’s disease
• Arthritis / Osteoarthritis
• Asthma
• Atrial fibrillation/flutter
• Cardiomyopathy
• Congestive heart failure
• Alcohol and drug use, abuse, and dependence
• Cerebral palsy
• Malnutrition
• Respiratory failure
• Stroke

Anemia

When submitting documentation of anemia, ensure to:

• Specify the type, such as nutritional, hemolytic, or aplastic.
• Indicate if the anemia is from nutritional or mineral deficits.
• Include the subtype of hemolytic anemia: hereditary, acquired, or enzyme disorder.
• Note any relation to chemotherapy or radiotherapy treatments.
• Specify if it’s caused by a neoplasm (primary and/or secondary).
• If drug-related, mention the name and purpose of the medication(s) causing anemia.

Diabetes Mellitus

The diabetes mellitus codes are combinations that include:

• The type of diabetes mellitus.
• The body system(s) affected.
• The complications affecting the body system(s).

When coding diabetes mellitus, utilize codes from categories E08-E13* to describe all associated complications and conditions. These diagnosis codes also determine the eligible population for the Comprehensive Diabetes Care quality measure.

If the physician specifies that diabetes mellitus isn’t the underlying cause, do not code it as a diabetic complication. The provider should be queried if it is unclear whether or not the two conditions are related.

Acute Renal Failure

Ensure to include the following when documenting acute renal failure, also known as acute kidney injury:

• Underlying condition(s) contributing/causing acute renal failure if known or suspected.
• Specification if the acute kidney injury (AKI) is caused by traumatic injury or from a non-traumatic event.
• Documentation if acute renal failure is from:
  • Acute tubular necrosis (ATN).
  • Acute cortical necrosis.
  • Acute medullary necrosis.
  • Other (specify).
• Any associated diagnoses/conditions.

Please note that acute renal insufficiency and acute kidney disease are not reported as acute renal failure.

Heart Failure

Heart failure occurs when the heart’s muscle doesn’t pump blood as efficiently as it should. When coding for heart failure, include the following specifications: 

• Acuity
  • Acute.
  • Chronic.
  • Acute on Chronic (i.e., decompensated or exacerbated).

• Type

• Diastolic.
• Systolic.
• Combined systolic and diastolic.

• Due to or associated with:
  • Cardiac or other surgery.
  • Hypertension.
  • Valvular disease.
  • Rheumatic heart disease.
  • Endocarditis (valvitis).
  • Pericarditis.
  • Myocarditis.
  • Other (specify).

Hypertension With Heart Disease

Code hypertension accompanied by heart conditions falling under codes I50.-I51.7, I51.89, and I51.9 to category I11, Hypertensive heart disease. Use additional codes from category I50, Heart failure, to specify the type(s) of heart failure present. 

If the provider deems the heart conditions unrelated to hypertension, code them separately. Sequence these codes based on the circumstances of the admission or encounter.

Coding Clinic 2023 Highlights

The Coding Clinic quarterly publication provides specific examples in a question-and-answer format. It offers guidance on documenting specific sequencing for diagnoses. BESLER’s webinar covered many topics from the 2023 Coding Clinics.

First Quarter

The first quarter’s questions pertain to the stages of chronic kidney disease. One scenario involves a patient admitted with acute blood loss anemia from a GI bleed, and another was admitted to rule out a GI bleed. Another example addresses end-stage renal disease and fluid overload issues.

Second Quarter

The second quarter publication includes an example where a patient was admitted for seizure evaluation and showed variable blood pressures and orthostatic episodes. Although the final diagnosis was “dysautonomia orthostatic hypotension syndrome,” specific codes describe the condition as related to type 2 diabetes mellitus.

Third Quarter

Coding Clinics’ Q3 publication includes two diagnoses: acute kidney injury and diastolic heart failure with improved recovered ejection fraction in acute-on-chronic right heart failure. Every admission’s circumstances differ, but the third quarter’s specific coding scenarios aim to help healthcare professionals navigate the complex field amid their day-to-day tasks.

Coding Tips & Best Practices

When coding medical records, carefully consider several key factors to ensure accuracy:

• Are principal and secondary diagnoses and procedures coded? 
• Were the coding conventions and guidelines followed?
• Does AHA Coding Clinic advice support or not contradict any coding concerns?
• Are any unspecified codes assigned with documented specificity? Is additional clarification needed?
• Has the team reviewed the MAR flowsheets, lab, radiology, and pathology reports?
• Are Present-on-Admission indicators accurately assigned?
• Is the discharge disposition properly documented?

Collaboration between coders and CDI professionals is crucial for correct medical coding. Staying current with coding and regulatory updates ensures adherence to industry standards and guidelines, thus enhancing documentation accuracy, ensuring proper reimbursement, and improving patient care outcomes. Together, you can optimize coding accuracy and integrity, reduce errors, and improve revenue cycle efficiency within your healthcare organization.

Yielding to the American Health Information Management Association (AHIMA) Standards of Ethical Coding is essential.

• Apply accurate, complete, and consistent coding practices that yield quality data.
• Gather and report all data required for internal and external reporting by applicable requirements and data set definitions.
• Only assign and report codes and data supported by health record documentation, following applicable conventions and requirements.
• Query and/or consult with the provider for clarification and additional documentation before final code assignment per acceptable healthcare industry practices.
• Do not support or engage in activities that distort or misrepresent data or coding practices.

Choose BESLER to Ensure Proper Coding Practices

BESLER’s services and software ensure coding accuracy and compliance, offering numerous benefits. With a suite of contingency-based services, BESLER provides optimal post-bill recovery, maximizing reimbursement for healthcare organizations.

Underpayment and validation services are available, even if you already have an existing vendor or internal process, providing an extra layer of revenue integrity. The seamless implementation process requires minimal IT involvement to streamline operations and minimize disruptions.

We offer a podcast and webinar for those seeking more insight into Coding Clinics from 2023. Tune in, gain valuable knowledge, stay updated on the latest industry trends, and enhance your coding expertise. We look forward to being your partner and working together.