ICD-10-CM Coding for Inpatient Professional Services

Featured coffee – White Chocolate Pumpkin Spice Latte

I received this question (I really need to start a coding forum):

Do principal diagnosis rules apply to coding for inpatient professional fee services?

No (and since by now, you know I don’t give short answers), here’s why.

In ICD-10-CM, services are identified as either inpatient or outpatient, and there are specific rules for principal (inpatient) versus first-listed (outpatient) diagnoses codes.

ICD-10-CM does not have rules or guidance specific to coding inpatient professional services; however, we know that inpatient professional services are billed on the CMS-1500 claim form to identify physicians’ work, other non-institutional providers, and suppliers.

Well, way back in 2000, ICD-9-CM Coding Clinic, Third Quarter 2000 and updated for ICD-10-CM in 2014, ICD-10-CM/PCS Coding Clinic, First Quarter 2014, AHA Coding Clinic issued guidance for the question regarding coding physician’s services during inpatient hospitalization. 

According to Coding Clinic, and of course, I’m summarizing due to copyright rules, when assigning codes for physician services, coders should follow Diagnostic Coding and Reporting Guidelines for Outpatient services.

Coding Clinic® is a registered trademark of the American Hospital Association Clinic

ICD-10® is copyrighted by the World Health Organization (WHO)

ICD – ICD-10-CM – International Classification of Diseases …. https://www.cdc.gov/nchs/icd/icd10cm.htm

Billing/Coding Compliance Plan

Featured coffee – Dutch Chocolate

I’ve seen so many questions on social media about starting coding or billing companies, and the number one question is about pricing.

How much to charge?

Should I charge per hour, per claim, or based on collections?

Well, my question (with my compliance hat on) is, do you have a compliance plan?

The Office of Inspector General (OIG) provides voluntary compliance program documents to help you create internal controls to ensure compliance with statutes, regulations, and program requirements.

Why is this important?

Well, are you following updates from the OIG’s enforcement actions, the OIG work plan items, or the list of OIG Corporate Integrity Agreements?  Yes, billing and coding companies are responsible for non-compliant activities when they knowingly violate the False Claims Act.

According to the OIG, “third-party medical billing companies are providing crucial services that could greatly impact the solvency and stability of the Medicare Trust Fund. Health care providers are relying on these billing companies to a greater degree in assisting them in processing claims in accordance with applicable statutes and regulations. Additionally, health care professionals are consulting with billing companies to provide timely and accurate advice with regard to reimbursement matters, as well as overall business decisionmaking. As a result, the OIG considers compliance program guidance to thirdparty medical billing companies particularly important in efforts to combat health care fraud and abuse.” 

By the way, medical coding is mentioned at least 70 times in the same guidance.

The OIG has developed seven essential elements that should be included in an effective compliance plan:

1. Implementing written policies, procedures and standards of conduct
2. Designating a compliance officer and compliance committee
3. Conducting effective training and education
4. Developing effective lines of communication
5. Enforcing standards through well publicized disciplinary guidelines
6. Conducting internal monitoring and auditing
7. Responding promptly to detected offenses and developing corrective action

Here’s the link to Compliance Program Guidance for Third-Party Medical Billing Companies. 

“Prove Them Wrong” Part 2 (Coding from the Findings)

Featured coffee – Brazil – Blue Diamond (Sage, dried apples, roasted peanuts)

Last week, I shared that I had a situation where I knew that my finding was correct, but I could not find a guideline to support me. 

So, this was the issue.

The provider documented the reason for the study (headache) in the clinical indication and documented mild generalized atrophy in the findings. In the impression, the provider documented “no acute abnormalities.”

The coder assigned the diagnosis for unspecified degenerative disease of the nervous system from the provider’s documentation, mild generalized atrophy” in the findings section of the report.
I failed the note. My finding was that the coder should have assigned the diagnosis code for headache documented in the clinical indication.

My rationale for not assigning the code for “mild generalized atrophy”?

• The provider did not document the finding in the impression.

If clinically relevant, the provider would have documented “mild generalized atrophy” in the impression.

• Coders should not assign codes from the findings.

Again, if the provider noted clinically relevant abnormalities in the findings, the provider would document it in the impression.

Sounds like my opinions, right? Well, that’s why I had to find credible resources to support my position because opinions don’t matter.

I don’t have a coding guideline or convention that states coders should not assign ICD-10-CM codes from the findings; however, I found this in ICD-10-CM Official Guidelines for Coding Reporting FY 2021 (October 1, 2020 – September 30, 2021), Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services, K – Patients receiving diagnostic services only.  “For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation.”

The above was confirmed in ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2017 Page: 5 Effective with discharges: March 13, 2017.

For incidental abnormal findings, ICD-9-CM Coding Clinic, Second Quarter 1990 Page: 15 to 16 Effective with discharges: April 1, 1990, clarifies that “Nonspecific abnormal findings, should be assigned only when the physician has not been able to arrive at a diagnosis based on an abnormal finding, but considers it clinically significant enough to list in the final diagnostic statement.”

According to American College of Radiology (ACR) Practice Parameter for Communication of Diagnostic Imaging Findings, A. Components of the Report, the recommended format should include (in addition to Clinical Indication and Technique), Findings and Impression (conclusion or diagnosis) sections and, “Unless the report is brief, each report should contain an “impression” or “conclusion.”

My interpretation of the coding convention, clarification in AHA Coding Clinic, and ACR Practice Parameters is that coders should assign ICD-10-CM codes from the interpretation/final diagnostic statement. Of course, if the impression shows normal results, coders should code the sign/symptom or other reason for the study documented in the clinical indication.

Coders should only use information in the findings for specificity, such as laterality.

If you have a different interpretation, please feel free to share it in the comments.

Coding Clinic® is a registered trademark of the American Hospital Association 
ICD-10® is copyrighted by the World Health Organization (WHO)
ICD – ICD-10-CM – International Classification of Diseases …. https://www.cdc.gov/nchs/icd/icd10cm.htm