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September 2016

Documentation? Who Needs It
By Lee DeOrio
For The Record
Vol. 28 No. 9 P. 3

I'm about as far from being a coding expert as Ryan Lochte is from being a leader of young men. Nevertheless, I always assumed the basis for all coding was founded upon the credo to code what is supported by the documentation. However, take a look at this incoming coding guideline:

Under A. Conventions, 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."

What about "Do not report and bill for a condition not supported by the documentation in the chart. Hold the account and query the physician for further clarification in such instances"? Apparently, those teachings no longer apply.

Take your standard admission. It's now OK to add "UTI" to the diagnosis list at discharge even though there's no mention of any urinary tract infection in the rest of the chart, not even symptoms or labs. Now coders are supposed to ignore those "minor" details. External auditors are always denying respiratory failure and HIV diagnoses (both of which are major complications or comorbidities) for lack of clinical support.

Is there a stink being raised about this? The new guideline seems to give carte blanche to physicians and promote lazy documentation, which has far-reaching consequences, especially in light of the harsh warnings to be mindful of copy-paste abuses. What does the Centers for Medicare & Medicaid Services (CMS) have to say? CMS consistently supports denials from recovery audit contractors that are based on "no clinical support for the diagnosis." What are coders supposed to do? Follow the guideline and get the provider in trouble with CMS?

A few industry experts, including Allen Frady, RN, BSN, CCS, CCDS, a senior consultant at Optum360, have raised the issue, but I have yet to hear further clarification or, better yet, an explanation of the thinking behind this guideline. At first glance, it seems counterintuitive to what the industry has preached for years, not only in terms of reimbursement but also how it affects data integrity and future patient care.

Then again, it wouldn't be the first time that the federal government was speaking out of both sides of its mouth.