New Guidance on Diagnoses, Clinical Evidence, and Abnormal Findings in ICD-10-CM Effective DOS Oct. 1, 2016

Over the years I have heard medical coders question the provider’s diagnosis. For example, someone might say, but how can you say the patient has CKD Stage III with that GFR lab? Or another might state, how can you say the patient has Protein Calorie Malnutrition, since the labs are all normal? There are many of these examples. We should always maintain a level of respect for providers and accept their stated diagnoses. Of course if there is something that seems completely improbable, it is always helpful to double check, but in general we should accept the provider’s diagnostic statements.

Because this seemed to be a real issue, there is new guidance in the ICD-10-CM that is effective for DOS starting Oct. 1, 2016. In the blue font below are new updates that establish that medical coders should accept the provider’s documentation that a diagnosis or condition exists, and that clinical criteria for such conditions or diagnoses is not necessary for proof.

A. Conventions for the ICD-10-CM

19. 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.

There were also questions by many coders on what constituted “abnormal findings.” This came in to question because when coding for example, Z00.0- Encounter for general adult medical examination, we have two options: using a .00 for “without abnormal findings” or using a .01 for “with abnormal findings.” Our original guidelines in the first issue of ICD-10-CM that was effective October 1, 2015, gave some guidance that we should code according to what was known at the time of coding and billing and that we did not need to wait for pending lab or other diagnostic studies, with a default being “without abnormal findings” if we were still unsure at the time.

However, new guidance expands the intentions of the two code selections as they pertain to abnormal findings. Below in blue is the excerpt on this new directive in our ICD-10-CM 2017, which is effective October 1, 2016.

Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services

P. Encounters for medical examinations with abnormal findings

An examination with abnormal findings refers to a condition/diagnosis that is newly identified or a change in severity of a chronic condition (such as uncontrolled hypertension, or an acute exacerbation of chronic obstructive pulmonary disease) during a routine physical examination.

This new guidance establishes that the intent of abnormal findings was not just about diagnostic testing findings, but should also be used when a new diagnosis or conditions is identified or whenever an acute exacerbation of a chronic condition exists.