Happy 9th Clinical Documentation Integrity Week
Telling the Patient’s Story
Happy Clinical Documentation Integrity (CDI) Week. Annually, the third week of September is a time to celebrate CDI Professionals who serve as a bridge between Coding and Clinical Professionals, helping ensure the patient’s “story” is accurate in the medical record. This year’s theme is CDI Superheroes: The Heroes Hospitals Deserve.
According to an Association of Clinical Documentation Improvement Specialists (ACDIS) Fact Sheet, “the growth of the CDI specialist profession has mirrored the healthcare industry’s increased focus on compliance with regulations, managed care profiles, payment for services rendered, quality of care improvement measurements, and liability exposure. All these factors increasingly depend on the integrity of complete and specific clinical documentation in the medical record.”
MMP would like to wish all of the hard working CDI professionals that we have the privilege to work with a happy CDI week. We also want to support your efforts by providing highlights from the ICD-10-CM Official Guidelines for Coding and Reporting for FY 2020.
The ICD-10-CM Officials Guidelines “have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are reported. The important of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”
You can find the FY 2020 Guidelines on CDC ICD-10-CM webpage as well as the 2020 ICD-10-CM CMS webpage. Additions to the annual guideline updates appear in bold. The following table highlights updates by topic, guideline text and the page(s) where you can find the update in the Guidelines.
|ICD-10-CM Official Guidelines for Coding and Reporting FY 2020 Updates|
|Topic||Guideline text||Page in pdf document|
|Zika Virus Infection||Code only a confirmed diagnosis of Zika virus (A92.5, Zika virus disease) as documented by the provider. This is an exception to the hospital inpatient guideline Section II, H. In this context, “confirmation” does not require documentation of the type of test performed; the provider’s diagnostic statement that the condition is confirmed is sufficient. This code should be assigned regardless of the stated mode of transmission.
If the provider documents "suspected", "possible" or "probable" Zika, do not assign code A92.5. Assign a code(s) explaining the reason for encounter ( such as fever, rash, or joint pain) or Z20.821, Contact with and (suspected) exposure to Zika virus
|Page 29 of 121|
|Other Types of Myocardial Infarction||Type 2 myocardial infarction (myocardial infarction due to demand ischemia or secondary to ischemic imbalance) is assigned to code I21.A1, Myocardial infarction type 2 with the underlying cause coded first. Do not assign code I24.8, Other forms of acute ischemic heart disease, for the demand ischemia. If a type 2 AMI is described as NSTEMI or STEMI, only assign code I21.A1. Codes I21.01-I21.4 should only be assigned for type 1 AMIs.||Page 52 of 121|
|Pressure Ulcer Stages||Pressure ulcer stages
Codes in category L89, Pressure ulcer, identify the site and stage of the pressure ulcer. The ICD-10-CM classifies pressure ulcer stages based on severity, which is designated by stages 1-4, deep tissue pressure injury, unspecified stage, and unstageable.
|Page 55 of 121|
|Pressure Ulcer Stages||Patients admitted with pressure ulcers documented as healed
No code is assigned if the documentation states that the pressure ulcer is completely healed at the time of admission.
|Page 56 of 121|
|Pressure Ulcer Stages||Pressure-induced deep tissue damage For pressure-induced deep tissue damage or deep tissue pressure injury, assign only the appropriate code for pressure-induced deep tissue damage (L89.--6).||Page 56 of 121|
|Non-Pressure Chronic Ulcers||Patients admitted with non-pressure ulcers documented as healed
No code is assigned if the documentation states that the non-pressure ulcer is completely healed at the time of admission.
|Page 57 of 121|
|Encounter for full term uncomplicated delivery||Code O80 should be assigned when a woman is admitted for a full-term normal delivery and delivers a single, healthy infant without any complications antepartum, during the delivery, or postpartum during the delivery episode. Code O80 is always a principal diagnosis. It is not to be used if any other code from chapter 15 is needed to describe a current complication of the antenatal, delivery, or postnatal period.||Page 66 of 121|
|Retained Products of Conception following an abortion||Subsequent encounters for retained products of conception following a spontaneous abortion or elective termination of pregnancy, without complications are assigned O03.4, Incomplete spontaneous abortion without complication, or codeO07.4, Failed attempted termination of pregnancy without complication. This advice is appropriate even when the patient was discharged previously with a discharge diagnosis of complete abortion. If the patient has a specific complication associated with the spontaneous abortion or elective termination of pregnancy in addition to retained products of conception, assign the appropriate complication code (e.g., O03.-, O04.-, O07.-) instead of code O03.4 or O07.4.||Page 68 of 121|
|Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)||Codes from Chapter 17 may be used throughout the life of the patient. If a congenital malformation or deformity has been corrected, a personal history code should be used to identify the history of the malformation or deformity. Although present at birth, a malformation/deformation/or chromosomal abnormality may not be identified until later in life. Whenever the condition is diagnosed by the provider, it is appropriate to assign a code from codes Q00-Q99. For the birth admission, the appropriate code from category Z38, Liveborn infants, according to place of birth and type of delivery, should be sequenced as the principal diagnosis, followed by any congenital anomaly codes, Q00- Q99.||Pages 72 - 73 of 121|
|Coding of Injuries: New Iatgrogenic Injuries||Iatrogenic injuries Injury codes from Chapter 19 should not be assigned for injuries that occur during, or as a result of, a medical intervention. Assign the appropriate complication code(s).||Page 77 of 121|
|Coding of Traumatic Fractures: New Physeal Fractures||Physeal fractures For physeal fractures, assign only the code identifying the type of physeal fracture. Do not assign a separate code to identify the specific bone that is fractured.||Page 78 of 121|
|Adverse Effects, Poisoning, Underdosing and Toxic Effects: If two or more drugs, medicinal or biological substances||If two or more drugs, medicinal or biological substances are taken, code each individually unless a combination code is listed in the Table of Drugs and Chemicals.
If multiple unspecified drugs, medicinal or biological substances were taken, assign the appropriate code from subcategory T50.91, Poisoning by, adverse effect of and underdosing of multiple unspecified drugs, medicaments and biological substances.
|Page 81 of 121|
|Complication of care codes within the body system||Complication codes from the body system chapters should be assigned for intraoperative and postprocedural complications (e.g., the appropriate complication code from chapter 9 would be assigned for a vascular intraoperative or postprocedural complication) unless the complication is specifically indexed to a T code in chapter 19.||Page 86 of 121|
|Status Z code: Z68 Body mass index (BMI)||BMI codes should only be assigned when there is an associated, reportable diagnosis (such as obesity). Do not assign BMI codes during pregnancy.||Page 94 of 121|
|Counseling – Code Z71||Persons encountering health services for other counseling and medical advice, not elsewhere classified
Note: Code Z71.84, Encounter for health counseling related to travel, is to be used for health risk and safety counseling for future travel purposes.
|Page 102 of 121|
|Selection of Principal Diagnosis: Uncertain Diagnosis (Inpatient Admissions)||If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.
|Page 109 of 121|
|Reporting Additional Diagnoses: Uncertain Diagnosis (Inpatient Admissions)||If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals
|Pages 111-112 of 121|
|Uncertain Diagnosis in Outpatient Setting||Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” “compatible with,” “consistent with,” or “working diagnosis” or other similar terms indicating 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.
Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.
|Page 114 of 121|
|Source: ICD-10-CM Official Guidelines for Coding and Reporting FY 2020 from CDC website at https://www.cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf.|
While new updates are highlighted in the table above, I believe reading the entire document annually is an excellent study guide for the new CDI Professional and review for those that have been in the profession for several years. Again, happy CDI week from our team to yours.
Article by Beth Cobb
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system.
This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.