Wiki Order of diagnosis severity in assessment/plan

[acw]

I am questioning whether it is the responsibility of the Coder to put diagnoses in order of severity when coding I-10 codes. Most of the physicians I code for do not do this in the their assessment/plan with their inpatient visits. I was told I had to figure it out. I guess I look at this as I am not a physician, and this would be diagnosing the patient when coding. I have asked that they document the most severe diagnosis first and then in order of severity in their assessments to no avail. I have searched all over the internet, AAPC, Coding guidelines for anything that is specific to this situation. so if anyone has anything that I could see in writing and I can gently educate on this, it would be most helpful. Thank you in advance.

 

[thomas7331]

Severity of the conditions is a criterion for the sequencing of a code - I'm not sure where you are getting that information. And I'm not aware of any guidelines or reason that you would need to ask a provider to document conditions in any particular order.

Per the ICD-10 guidelines, Section IV.G., your first-listed code should be the condition that is primarily responsible for the encounter you are coding, not the most severe condition: "List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided." Since documentation of a chief complaint is a requirement for all E/M services, it should be easy to identify the diagnosis code based on that information. Then, per Section IV.J., you would add additional codes for "all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management." There is no requirement to document or code these in any particular order, and unless your organization has given you some kind of internal requirement to do so, it would not be a good use of your time to do so because the sequence of additional codes after the first one does not affect reporting or payment in any way.

 

[acw]

Thank you for the response. I agree with all of this; however, the assessments do not have the first listed diagnosis as "the reason why patient is being seen." Example that patient is being seen for severe sepsis with shock, and the first code is hypertension, and the 9th diagnosis is the sepsis. I will always code these type of severe illnesses first, but sometimes, it is hard to figure out why the patient is being seen that particular day. Yes, first thing I look for is a chief complaint. The physicians rely on our 100% abstraction of the note for both E/M visit code and I-10 diagnosis codes. We have asked that they help us out with their documentation to at least give the most severe diagnosis for that day first in the their assessments.
Thank you again for the ICD-10 guidelines.

 

[thomas7331]

Thank you for the response. I agree with all of this; however, the assessments do not have the first listed diagnosis as "the reason why patient is being seen." Example that patient is being seen for severe sepsis with shock, and the first code is hypertension, and the 9th diagnosis is the sepsis. I will always code these type of severe illnesses first, but sometimes, it is hard to figure out why the patient is being seen that particular day. Yes, first thing I look for is a chief complaint. The physicians rely on our 100% abstraction of the note for both E/M visit code and I-10 diagnosis codes. We have asked that they help us out with their documentation to at least give the most severe diagnosis for that day first in the their assessments.
Thank you again for the ICD-10 guidelines.

Perhaps I'm not completely understanding what exactly your situation is here - it sounds almost like your providers are coding their own E&M claims and you're just reviewing them after the fact? If that's the case, I'd continue giving them feedback, but not be too concerned about the first-listed code being in the wrong place because truthfully, it's not going to affect payment at all on a physician claim and I can't imagine this would cause your provider a problem in an audit. Or are they coding within their documentation but then you're recoding the information onto the final claim and struggling because you can't determine which code to list first on your claim?

The first-listed diagnosis refers to being the first-listed code on the claim, not in the assessment or documentation. So if the provider stated that the patient was being seen for the severe sepsis with shock, then that's what I'd report as the first-listed code. If there are multiple reasons why they saw the patient, then you can really pick any one of those. I'd probably also try pick the one that appears to be of highest severity, but again, on a physician claim this really doesn't affect payment, and this would be just kind of a technicality so I really wouldn't invest too much thought or time into it. On the other hand, if the documentation is completely missing a chief complaint and or primary reason for the visit and it's truly impossible to tell why the provider saw the patient, then that is a deficiency in documentation per the CMS E/M documentation guidelines, and in that situation I would probably query them to add the missing information.

The choice of the principal diagnosis is critical on an inpatient hospital claim because that can change the DRG and payment dramatically. But on a physician claim, the sequence very rarely, if ever, affects payment, so the compliance implications and risks of causing an improper payment are of much lower concern. As long as all of your codes are properly supported by the documentation, I don't think you need to consider code sequence to be a big issue.

I hope that helps some!

 

[acw]

Thank you for this explanation! And thank you for the time it took to type all of this!

We do all the coding for the physician profee visits...they only document their note. We figure out the E/M service and all the I-10 codes. And I did get tired of racking my brain, and just decided to code the first I-10 code what I thought would be the most severe (i.e. septic shock). The rest of the diagnoses, I just go down the line and code each diagnosis. While I have been coding for three decades and know pathophysiology pretty good, there are times that when reading so much, my brain can get fried trying to figure out diagnoses severity ( I do know how to code all the codes that have presumptive codes to add, like HTN/CHF, DM manifestations when documented).

Take care!
ACW