News: Updated ICD-9-CM Official Guidelines for Coding and Reporting contain several changes that impact clinical documentation specialists

On August 6, the National Center for Health Statistics (NCHS) released the updated ICD-9-CM Official Guidelines for Coding and Reporting. The changes are effective October 1, 2008.

Although the NCHS updates the guidelines annually, this year’s additions/revisions were heavier than usual, says Shannon McCall, RHIA, CCS, CPC-I, director of HIM and coding for HCPro, Inc., in Marblehead, MA, and a member of the ACDIS advisory board.

The guidelines were expanded to state that a coder can derive the stage of a pressure ulcer from a clinician who is not the patient’s provider, which is critical because many nurses document the stages of pressure ulcers very well.

But don’t be fooled: The guidelines go on to state that the documentation required to assign the associated diagnosis code for the site of the pressure ulcer must still come from the provider, McCall says. “Per the new guidelines, you need to report two codes for a pressure ulcer: for the site and the stage, so documentation for both is equally important.”

The same principle applies to body mass index (BMI)—the guidelines state that you can use a clinician’s documentation to code the patient’s BMI, but the associated diagnosis (e.g., overweight, obesity) must be documented by the patient’s provider. Unlike pressure ulcers, however, the instructional notes do not require a coder to report codes for both obesity and BMI. “You only assign both codes if known and documented in the medical record,” McCall says.

“The expansion of pressure ulcers is a good thing, but it’s still fundamentally different as you can assign a BMI on its own, off of a dietician’s note, but for a pressure ulcer you still might have to query the physician because you can’t assign a site for a pressure ulcer without a provider’s documentation,” she adds.

Present on admission (p. 104)

The guidelines clear up a confusing POA reporting quandary, and now state that you can report a POA Y indicator even if the physician needed several days after the patient’s admission to arrive at a definitive diagnosis. From the guidelines:

CMS also provided an example of a patient who had a urine culture performed on admission, but was not diagnosed with a urinary tract infection (UTI) until the culture results become available later in the stay from the lab. “The question was, previously, which POA indicator do we assign, considering on admission the provider may have suspected that the patient had a UTI based on signs/symptoms, but could not reach a definitive diagnosis without confirmation of the lab results,” McCall says. “The answer they expanded on in the examples was that you assign a Y.”

Note that the guidelines define a provider as a physician or any qualified practitioner legally accountable for establishing a patient’s diagnosis.