One of the more prominent guidelines found in the ICD-10-CM Official Guidelines for Coding and Reporting is Section III. Reporting Additional Diagnoses but it isn’t always applied appropriately.
The guideline states: For reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:
clinical evaluation; or
therapeutic treatment; or
diagnostic procedures; or
extended length of hospital stay; or
increased nursing care and/or monitoring
It also draws from the Uniform Hospital Discharge Data Set (UHDDS) item #11-b which defines Other Diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded”. UHDDS definitions were the product of a 1985 Federal Register (Vol. 50, No.147) and are used by acute care short-term hospitals to report inpatient data elements in a standardized manner. They have since been expanded and applied in other non-outpatient settings such as long-term care and psychiatric hospitals.
Before you assign a secondary diagnosis to consider whether the condition meets any of the elements for affecting patient care noted above.
The physician documents a condition in the medical record. Before coding the diagnosis, ask yourself questions related to the criteria outlined in the guideline: What medications did the patient receive? What laboratory and radiology procedure were performed? What time-consuming nursing care was provided? What condition is being evaluated by a consultant? And, do those services directly relate to the diagnosis to be coded.
Ask yourself, could you justify the coding of the condition based on the official guideline. One area that tends to be problematic in payment denials is the coding of a condition that has no bearing on the current hospitalization even though it may be clearly documented by the physician. This is particularly evident in payers that use the All Patient Refined (APR) groupers for reimbursements such as Blue Cross/Blue Shield and Medicaid programs. Sometimes a seemingly minor condition may impact the DRG reimbursement unexpectedly. If that condition doesn’t meet the reporting of additional diagnoses guideline, potentially it could be denied for additional reimbursement.
One example is vitamin D deficiency (E55.9). This condition may be reported in the past medical history section of the history & physical. It should not be reported automatically without checking its impact on the current patient care. Was the patient’s vitamin D level checked? Did the patient receive vitamin D supplementation during hospitalization?
However, some conditions documented in the past medical history may be pertinent to code as they co-exist at the time of admission and the patient’s care is affected. Some common diagnoses in this category are atrial fibrillation, hypertension, and congestive heart failure. Though the conditions may not be prominent in the current hospitalization for an unrelated diagnosis, they may still be pertinent and appropriate to code. The patient may be on maintenance medications for the treatment of the atrial fibrillation (e.g., Coumadin), hypertension (e.g., Atenolol) and congestive heart failure (e.g., Lasix).
As you code your secondary diagnoses, keep in mind the criteria found in Section III. Reporting Additional Diagnoses. It will not only provide a more accurate database but offer support should a diagnosis be questioned in a payment denial.