The ICD-10 partial code freeze is over and effective October 1, 2016 there will be many changes to the ICD-10 code set. Recently both the Centers for Disease Control and Prevention (“CDC”) and Centers for Medicare & Medicaid Services (“CMS”) released the 2017 ICD-10-CM and ICD-10-PCS codes. Below is the breakdown of the changes:

Here are some of the key changes in the updated code set:

In addition to the update to ICD-10 diagnosis and procedure codes, CMS published the 2017 Inpatient Prospective Payment System (“IPPS”) final rule. Included in the final rule is an update to Section I of the ICD-10-CM Official Guidelines for Coding and Reporting, which has caused some controversy in the coding community. The controversy stems from the new guideline entitled Code Assignment and Clinical Criteria, which states:

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.

While the issue to code or not to code when documentation is lacking is not new, this new guideline does put facilities in a corner. If a facility decides not to code a diagnosis due to poor documentation, the facility is out of compliance with the new coding guideline. However, if the facility codes the diagnosis, the facility may be assessed with an overpayment from the Recovery Auditors for lack of documentation to support the assigned code. Time will tell if Recovery Auditors will accept the new guideline as justification for coding diagnoses without the support of clinical indicators (it is unlikely). In the meantime, we recommend the following:

• Continue to maintain strong clinical documentation standards that fully describe the true complexity and severity of a patient’s stay
• Continue to request from clinicians that symptoms and clinical findings (labs/tests) are linked to diagnoses
• Partner with CDI staff to ensure documentation supports documented diagnoses through the physician query process
  • The new guideline states that code assignment is not based on clinical criteria but in no way does it discourage coders and CDI specialists to clarify a diagnosis if there is conflicting, ambiguous or insufficient documentation to support a code
• Ensure that coding staff is trained on the updates to the ICD-10 code set and Official Coding Guidelines

See how Provident’s  DocEdge™ Communicator can help manage the query process and reduce physician response times