Health Information Management

Editor's Note: Correction: Coding Clinic vs. coding guidelines: Which takes precedence?

HIM-HIPAA Insider, August 24, 2010

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Editor’s note: HIM Connection reprinted the following Q&A in our August 17 issue. JustCoding has since issued a correction. Please see the revised answer below. We apologize for the error.

Q: An auditor recently reviewed a chart for an inpatient stay. The patient was admitted due to an intestinal obstruction caused by cancer. No surgery was performed. The patient was monitored. The auditor stated that the intestinal obstruction should be the principal diagnosis because we treated the obstruction, not the cancer. Even though we referenced a Coding Clinic that stated that the cancer is the principal diagnosis, the auditor stated that coding guidelines take precedence over Coding Clinic.
A: Although it can be extremely difficult to give definitive advice without seeing the entire medical record, it is important to remember that there are generally two sources of authority for ICD-9-CM code assignment: The ICD-9-CM Official Guidelines for Coding and Reporting and the American Hospital Association’s (AHA) Coding Clinic. Both sources can be good places to start when researching a coding question or scenario.
The ICD-9-CM Official Guidelines for Coding and Reporting mainly give general guidance on proper code assignment and sequencing, however there can be many different scenarios that guidance in the official guidelines does not specifically address.
The AHA’s Coding Clinic has long been considered a source authority for proper ICD-9-CM code assignment. This quarterly newsletter has been providing coding advice since 1984 and is published by one of the four Cooperating Parties who maintain the ICD-9-CM diagnosis codes. Coding Clinic advice generally addresses very specific scenarios based on questions posed by its readers for which code assignment may be considered a bit ambiguous or subjective because it is not specifically addressed in the ICD-9-CM Official Guidelines for Coding and Reporting or the 2010 ICD-9-CM Manual.
The preface to the ICD-9-CM Official Guidelines for Coding and Reporting does specifically state that adherence to the conventions and instructions provided within ICD-9-CM are required. However it is important to note that the guidelines do not address this particular scenario described above, therefore reliance on Coding Clinic is necessary and helpful.
The guidelines address sequencing for neoplasms when present with metastatic sites, as well as admissions for treatment (surgical or nonsurgical) for a neoplasm, but they do not specifically address the sequencing when the cancer has caused an obstruction. There is no such instruction within the coding manual that identifies a convention or instructional note like “use additional code” and “code first” when it pertains to cancer and obstructions.
To see a list of the conventions and instructional notes in the 2010 ICD-9-CM Manual, you can reference them in Section 1A of the ICD-9-CM Official Guidelines for Coding and Reporting.
Based on the scenario you described above, it is unclear to me that the cancer actually caused the obstruction in the intestine, but given your question I presume the documentation stated this very clearly. Coding Clinic, second quarter 1997, did address a similar question pertaining to a carcinomatosis causing a small bowel obstruction. The guidance was to assign the code for the neoplasm as the principal diagnosis. Presumably, the thought process is that the obstruction is a complication of the underlying cause, which was the cancer.
As coders, we must rely on the authoritative guidance with which we are provided to appeal and substantiate proper code assignment.
I recommend writing to the AHA Coding Clinic for additional clarification if necessary.
Editor’s note: Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro Inc., in Marblehead, MA, answered this question. This answer was provided based on limited information submitted to Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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