QUALITY DATA: CODING

GUIDELINES
BIO 312 E
Erin Frankenberger & Michelle Wisniewski

ICD-9 CODING GUIDELINES

Provided by CMS and NCHS
Found in the beginning of the ICD-9-CM
Codebook, or on the AMA website
These are a "set of rules that have been
developed to accompany and
complement the official conventions
and instructions provided within the
ICD-9-CM itself"

UNCERTAIN DIAGNOSIS
A record may have documentation that may
include the words "probable", "suspected",
"questionable", or "rule out

In an outpatient setting, these conditions

should not be coded
However, the conditions should be coded to
the highest degree of certainty for that
encounter (symptoms, signs, etc.)

UNCERTAIN DIAGNOSIS
When faced with an uncertain
diagnosis in an inpatient setting, the
rules are a bit different
If the diagnosis is documented at the
time of discharge and includes the
terms "probable", "suspected", "likely",
"questionable", "possible", or "still to
be ruled out", the condition should be
coded as if it existed

UNCERTAIN DIAGNOSIS
Even with these rules pertaining to
uncertain diagnoses, you must still
remember to look for diagnostic
workup, observations, and the initial
therapeutic approach to confirm the
actual presence of a specific diagnosis

QUERY PROCESS
When a coder is unsure of a code
assignment, the physician who
provided the documentation should be
queried
As per the AHIMA Standards of Ethical
Coding:
"Query the provider for clarification and additional
documentation prior to code assignment when there is
conflicting, incomplete, or ambiguous information in the health
record regarding a significant reportable condition or
procedure..."

DOCUMENTATION EXPECTATIONS
The primary purpose of the health
record is to document patient care
It is also a tool for professionals to
communicate with each other regarding
the patient care
According to CMS, documentation is
expected to be "legible, complete, clear,
consistent, precise, and reliable"

DOCUMENTATION EXPECTATIONS
In addition to providing clear
documentation, physicians are
also required to abide by the
medical staff bylaws and be
proactive in the development of
query policies and procedures

EXAMPLE
An 84-year old patient was admitted into the hospital
complaining of shortness of breath, leg edema, a left
upper extremity mass and a decubitus ulcer on her
heel
Examination of the patient revealed a lengthy list of
problems, including congestive heart failure,
possible pneumonia, atrial fibrillation, and dementia
The patient underwent x-rays, blood work, an
echocardiogram and other diagnostic testing to
confirm the above diagnoses
The patients treatment plan included medication,
physical and occupational therapy and consultation

EXAMPLE
The patient was assigned an ICD-9 code for
pneumonia as a secondary diagnosis
However, the assignment of this code was
rejected by the RAC during an audit
The RAC rejected the claim on the grounds
that the diagnosis of pneumonia was not
supported by clinical evidence

EXAMPLE
This is the Recovery Audit Contractors document:

EXAMPLE

This discharge summary includes the

pneumonia diagnosis, as well as the
medication that was given as treatment.

EXAMPLE

This was taken from the history & physical

which also supports the diagnosis of
pneumonia

EXAMPLE

This is taken from the x-ray report which also

supports the presence of pneumonia

EXAMPLE
The coder was justified in the assigning of
pneumonia as a secondary diagnosis
Even though it is documented that the
pneumonia is questionable, there is
substantiating documentation that
supports this diagnosis
The patient was not only given antibiotics,
but there was also evidence of pneumonia
in the history & physical and X-ray

REFERENCES
http://www.jfponline.com/fileadmin/content_pdf/fpn/archive_pdf
/vol38iss14/70932_main.pdf
http://www.vhca.org/IlluminAgeApps/whatsnewApp/files/613A4
4DAC.pdf
http://www.californiahealthline.org/articles/2013/9/4/oigmedicares-recovery-audit-program-more-accurate-thanbelieved
http://www.cms.gov/Research-Statistics-Data-andSystems/Monitoring-Programs/recovery-auditprogram/index.html?redirect=/rac/
http://www.amaassn.org/resources/doc/cpt/icd9cm_coding_guidelines_08_09_
full.pdf