Were We Asleep at the Wheel? Changes to the Official Guidelines for Coding and Reporting 2017

Yesterday was certainly like any other, in the world of healthcare coding, clinical documentation improvement (CDI) and appeals. The work is intriguing, interesting, and certainly a learning experience every day. The only thing that made this day different was taking a look at the changes to the Coding Conventions for the 2017 Official Coding Guidelines for Coding and Reporting. Oddly enough, providers would think the updates could not be that bad after surviving ICD-10 but on the other hand, could they and did providers fall asleep or lose focus as we grappled with MACRA (Medicare Access and CHIP Authorization Act), IPPS (Inpatient Prospective Payment System) Final Rule, Quality Initiatives like PQRS (Physician Quality Reporting System), Readmissions, Value Modifier, Patient Safety Indicators, just to name a few and certainly providers probably deserve a nap. It has been a long couple of years and someone’s foot is still on the gas.

Providers utilize the Official Coding Guidelines for appropriate code assignment of ICD-10 diagnosis and procedure codes which ultimately leads to payment of a DRG for inpatient and can justify medical necessity for service within the outpatient arena. These guidelines are approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), Centers for Medicare and Medicaid Services (CMS), and National Center for Health Statistics (NCHS). As stated in the guidelines, “Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance 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.” The guidelines go on to say, “Only this set of guidelines, approved by the Cooperating Parties, is official”, and become effective October 1 of every year coinciding with the IPPS Final Rule effective date.

This year’s update has quite a few significant changes that could potentially have far reaching implications that certainly requires more review and conversation. Somehow many providers missed this change.  Follow along for a deep dive.

  • Providers have struggled with the Excludes1 definition as in some cases a condition could be unrelated to another. The guidelines give the opinion that the provider should be queried if it is unclear to code separately.


  • “An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider.” (ICD-10-CM Official Guidelines for Coding and Reporting; FY 2017)


  • Not too concerning as at times it is often necessary to query the provider when documentation is not clear for appropriate code assignment. This may impact the query process or require increased need for up front education for the provider.


  • Another area that has growing concern over the past year and has recently gotten the attention worthy of AHA Coding Clinic publishing is the term “with” (interpreted as “associated with” or “due to”). The premise of this word is to show linkage between conditions or diagnoses; hence establishing a relationship. Initially the focus of the use of this term was around diabetes but as it is utilized throughout the index as a common staple, the need existed to address overall. An example would be diabetes with cataract.


  • “The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related.” (ICD-10-CM Official Guidelines for Coding and Reporting; FY 2017)


  • In the past guidance was given to providers that establishing a relationship in the documentation was required in some cases with the use of this term. This will certainly impact code assignment and statistics. An example would be the 86 year old (Hi Mom!) that has had a cataract for years and is just developing diabetes on the admission or encounter. Will this be assigned to a senile cataract or a diabetic cataract? Is documentation good enough for correct code assignment, can the problem list help, no looking at the previous admission for help right?


  • One of the most significant changes to guidelines is related to clinical criteria and code assignment. Over the past few years, providers have embraced the need for clinical documentation improvement programs and quite frankly battled regulatory scrutiny in relation to the diagnosis the physician has assigned and clinical support in the chart based on clinical criteria or indicators like labs, radiology, vitals, medications, treatment, and other interventions. This disconnect between criteria and code assignment led to the “Clinical Validation” Review process. This process was initially laid out in the Recovery Audit Contractor, RAC, Statement of Work, but quickly became a tool utilized by all payers to remove principal diagnoses as well as secondary, MCCs (Major complications and comorbidities) and CCs (Complications and comorbidities). Of course it is common knowledge that the OIG and DOJ have utilized this process to some degree since the late 80’s – early 90s when it was initially seen with the noncompliant reviews for pneumonia that were really bronchitis or asthma. Is coding going a step back or should that be decades back? Or was this the dilemma and it is being rectified?


  • “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.”  (ICD-10-CM Official Guidelines for Coding and Reporting; FY 2017)


  • This will certainly stir some chickens from the roost. Since noting and sharing with colleagues there has been quite the buzz and I would say for the most part not the happy kind; more like wasps than bees.

Food for thought:

  • Does this really mean only the physician documentation counts?
  • Is there no longer the need to worry about contractors appropriately and inappropriately utilizing clinical validation?
  • Is there the same need for CDI professionals or will we just perform more training?
  • Will more CDI be utilized?
  • What about the Department of Justice (DOJ) and the Office of Inspector General (OIG)? What will the stance be from these agencies?
  • Is CMS ready to increase reimbursement to hospitals when short-stay claims begin to be coded with MCC or CC diagnoses that are not clinically validated like: sepsis, acute respiratory failure, encephalopathy?
  • How will this impact our coded data?

As providers get their arms around this change, it is important to remember there are other references to follow included in the guidelines as restated in the CMS Medlearn Matters Article # – SE1121 states, “As with all codes, clinical evidence should be present in the medical record to support code assignment. The Uniform Hospital Discharge Data Set (UHDDS) Guidelines for coding and reporting secondary diagnosis allow the reporting of any condition that is clinically evaluated, diagnostically tested for, therapeutically treated, or increases nursing care or the length of stay of the patient.”

This topic will certainly get much discussion over the coming months and many are wondering how in the heck did this topic get overlooked within industry? Stay tuned as this new era unfolds.

Sharon Easterling, MHA, RHIA, CCS, CDIP, CPHM, FAHIMA

Recovery Analytics, LLC

ICD-10-CM Official Guidelines for Coding and Reporting; FY 2017; (October 1, 2016 – September 30, 2017)

CMS Medlearn Matters Article # – SE1121

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