ICD-10-CM Official Guidelines

1

• ICD-10-CM Official Guidelines

2
ICD-10-CM Official Guidelines
As per ICD10-CM Official Guidelines, your choice
of diagnosis code is based on the actual
diagnostic statement provided by physician. But
it depends on case to case basis. The Official
Guideline Wording The 2019 ICD-10-CM Official
Guideline (OG) Coder always assigns code based
on the providers diagnostic statement. The
providers statement that the patient has a
particular condition is sufficient. Code
assignment is not always based on clinical
criteria used by the provider to provide the
diagnosis. You can consider that the medical
coding is depends on provider documentation
because the provider is the one who responsible
for diagnosing the patient. Coding
Challenges Coders may confuse when that the
documentation for the case does not support
current clinical criteria for the diagnosis that
the provider records.
Medical Billing Services in Oregon
3
ICD-10-CM Official Guidelines

• While starting coding first point should be this
  While physicians may use a particular clinical
  definition or set of clinical criteria to
  establish a diagnosis, the code is based on
  his/her documentation, not on a particular
  clinical definition or criteria. This quote is
  from AHA Coding Clinic for ICD-10-CM and
  ICD-10-PCS (2016, vol. 3, no. 4).
• If clinical validation reviewer disagrees with
  the providers diagnosis then this is not a
  coding issue, this is a clinical issue.
• Coders should follow one important guideline that
  they should not code sepsis in the absence of
  physician documentation.
• Coding tips When severe sepsis is documented,
  there will be a minimum of two codes when using
  ICD-10-CM a code for the underlying systemic
  infection, followed by a code for severe sepsis,
  R65.2-. If organ dysfunction other than septic
  shock is present, the codes for the specific
  organ dysfunction are added.
• Coder should always keep in mind that the basic
  rule of coding is to assign codes based on the
  providers diagnostic statement. But as we
  discuss above this is not always possible.
  Consider case of experienced coder who has been
  working in specialty for many years

Medical Billing Services in Oregon
4
ICD-10-CM Official Guidelines

• If he or she cannot follow how a doctor got to
  the final diagnosis based on whats documented,
  then its possible an auditor for a payer wont
  be able to follow it either. Consider in this
  case that the auditor may determine that payment
  was inappropriate, meaning the payer will demand
  the money back. Such documentation may lead to
  legal cases, too.
• So, conclusion is that its an organizations
  responsibility to have a clear process for
  handling documentation that seems to not support
  the final diagnosis. Everyone has to know their
  own role clearly defined be it coder,
  documenting provider and possibly a provider
  assigned to be the reviewer in such cases.
• We suggest you to hire coder from us or outsource
  your medical coding process to us for better
  process. We have clear transparency in our
  reporting to physicians. We have very experienced
  and certified medical coding staff with defined
  coding process.
• About Medisys
• We are a group of medical billing experts who
  offer comprehensive billing and coding services
  to doctors, physicians hospitals. We provide
  end to end billing and coding solutions. Medisys
  Data Solutions RCM solutions ensures that the
  providers recover every they are entitled to.
  Our vision for the providers is You Cure. We
  ecure.

Medical Billing Services in Oregon