Proper Diagnosis Under ICD-10-CM: Don’t be a Coding ‘Minimalist’

Mastering the use of additional diagnosis codes (and knowing when to use them) is incumbent upon wound care professionals since the coding conversion.

One of the toughest hurdles for healthcare providers to overcome in what is now an ICD-10-CM world has been learning when to use additional diagnosis codes other than the first-listed code. Many wound care professionals want to document/code to simply be paid … period. They may be wondering, “Why should I code anything other than the reason for the encounter or visit?” This article will examine the importance of using additional diagnosis codes in addition to the main reason for the patient’s encounter and offer insight as to why these additional codes are important in an attempt to help clinicians avoid becoming “coding minimalists.” Wound care providers must remember that it’s not advised to code simply to get paid. Instead, ICD-10 specificity codes should be utilized to accurately demonstrate the comprehensive care being given to wound care patients.

Defining “Other Diagnoses”

For reporting purposes, the definition for other diagnoses is interpreted as “additional conditions that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring. Diagnoses that relate to an earlier episode of care that have no bearing on the current encounter should be excluded.”¹ Let’s take a look at some of the 2016 outpatient coding guidelines set forth by the Centers for Medicare & Medicaid Services. NOTE: Although the ICD-10 conventions and general guidelines apply to all settings, coding guidelines for outpatient and wound care professional reporting of diagnoses will vary (in a number of instances) from those for inpatient diagnoses.

Previous Conditions

If the clinician included a diagnosis in the final diagnostic statement, such as on the cover sheet of the encounter, that diagnosis should ordinarily be coded. Some wound care professionals tend to document resolved conditions or diagnoses and status post-procedure from previous admissions/encounters that have no bearing on the current encounter. Such conditions should not be reported and should only be coded if required by facility policy. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. Some examples of these previous conditions that should be considered are: previous history of malignancy, family history of disease, and status codes that may describe the patient’s current condition (eg, a below-the-knee amputation).

Selection of First-Listed Condition

In the outpatient setting, the term first-listed diagnosis is used in lieu of the term principal diagnosis that is used for coding inpatient cases. In determining the first-listed diagnosis, the coding conventions of ICD-10 (as well as the general and disease-specific guidelines) take precedence over the outpatient guidelines. Outpatient diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is actually confirmed. For example, coding a sign or symptom as a first-listed diagnosis is acceptable if the testing has not been completed to identify a specific disease state and rationale for outpatient testing. Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” “working diagnosis,” or other similar terms because they indicate uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reasons for the visit. Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (ie, confirmed) by the provider. Chapter 18 of the ICD-10 Tabular List of Diseases and Injuries, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00-R99), contains many (but not all) codes for symptoms.

Outpatient Surgery 

When a patient presents for outpatient surgery (same-day surgery), the reason for the surgery is coded as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication. Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” “working diagnosis,” or other similar terms that indicate uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.

Chronic Diseases 

Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).

Code All Coexisting Documented Conditions

Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care, treatment, or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history impacts current care/influences treatment.

Ambulatory Surgery

For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive. Multiple resources (including the American Health Information Management Association, various professional organizations, government programs such as the Physician Quality Reporting System, and Meaningful Use requirements) provide many reasons for which wound care professionals should start to think more “outside the box” when considering data to collect and information to document. The following is a set of examples listing some of the benefits that can be seen when wound care professionals avoid becoming ICD-10 minimalists: 

• Better data collection demonstrates improved patient outcomes.

• More specificity allows for meaningful data capture for research. (Under the ICD-9 system it was difficult, if not impossible, to drill down to specific characteristics and descriptions of disease states.)

• Identifying certain managed chronic conditions assists in the long-term management of certain diseases.

• The specificity of the ICD-10 codes helps wound care professionals demonstrate the severity of illness or complex case-mix population that they serve.

• In conjunction with improved documentation efforts and specific diagnosis coding, the process of coverage, coding, and payment should become more efficient (ie, less payer misinterpretation and hopefully a reduction in requests for copies of patient records).

• Better data allows for improved communication between caregivers because of diagnosis-code specificity.

•  Specific diagnosis codes assist in reflecting quality indicators. (Many payers have financial rewards for wound care professionals who meet the payer’s designated quality performance indicators.)

• Proper coding provides wound care professionals with an accurate representation of the patient population they serve.

Resource

1. ICD-10-CM Official Guidelines for Coding and Reporting Fiscal Year 2016.

Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, is senior director, reimbursement services, national policy and payer access at Integra LifeSciences Corp., Plainsboro, NJ, and an approved ICD-10 trainer by the American Health Information Management Association. She may be reached for questions at 609-936-2265 or at donna.cartwright@integralife.com