This Independence series, ICD-10 in Action, features articles to recap some of the ICD-10 diagnosis code changes, introduce new coding scenarios, and communicate updates to ICD-10 coding conventions.
The ICD-10-CM Manual contains official guidelines for coding and reporting. There are coding conventions, general coding guidelines, and chapter-specific guidelines, as described below, which must be followed to classify and assign the most appropriate ICD-10 code when submitting a claim. Understanding these guidelines and conventions is key to reaching the most appropriate code assignment.
- Conventions. A set of rules for use of the classification independent of the general or chapter-specific guidelines. Coding conventions and instructions of the classification take precedence over guidelines. (e.g., Code First).
- General guidelines. A set of rules and sequencing instructions for using the Tabular List and Alphabetic Index. These guidelines provide rules such as how to locate a code and obtain level of detail.
- Chapter-specific guidelines. A set of rules for specific diagnoses and conditions in a particular classification.
As with ICD-9, adherence to these guidelines is required under the Health Insurance Portability and Accountability Act (HIPAA).
Coding convention ? Common reporting errors
Mistakes and accidents are part of life and, at times, unavoidable. However, when it comes to errors in clinical documentation and reporting, mistakes and accidents can be costly and detrimental for both providers and patients.
Here is a hypothetical scenario:
A 35-year-old female went to see her endocrinologist for treatment and management of Polycystic Ovarian Syndrome (PCOS). The endocrinologist performed a routine treatment plan, which includes monitoring lab results as well as refilling or adjusting prescriptions as necessary. The patient said she was experiencing gastrointestinal side effects from the prescribed drug Glucophage®. The physician recommended she try Glucophage® XR (extended release) instead, as this formulation may reduce or eliminate the side effects she experienced. Six months later, the patient started receiving calls from a health coach at her insurance company as a courtesy to help her manage her ?diabetes.? The patient is confused because she does not have diabetes.
This health coach call occurred because someone reviewing the patient's clinical documentation saw the patient was taking Glucophage®, a common diabetic medication, assumed she had diabetes, and used the incorrect coding convention to document the "diagnosis." Because the wrong coding convention was used, the wrong condition was assigned to the patient. The patient is taking Glucophage® XR for insulin resistance, which is a common condition of PCOS.
Thankfully there were no medical or cost impacts to the patient. However, there were many letters mailed and phone calls made to trace the source and correct the diagnosis. There could have been a great impact to the patient, especially if the medication was not covered for the diagnosis of PCOS.
Even though the above scenario may not be common, there are some common reporting errors that can cause delays, denials, or rejected claims. To avoid these errors, it is important to make sure the documentation is clear and the coding is accurate for the condition and services performed.
When providing code assignment, the diagnosis code that describes the patient's diagnosis, symptom, condition, or complaint must be reported.
Here are some examples of common reporting errors: