We are considering developing internal coding guidelines and obtaining medical staff approval to code acute blood loss anemia. The guidelines would specify lab values pre- and post-surgery, as well as some clinical signs to allow coders to code acute blood loss anemia without the need to have physician documentation. Would this be acceptable?
No, it is not acceptable. The Official Coding Guideline Section III.B., states: “Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. If the findings are outside the normal range and the physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether the diagnosis should be added.” Therefore, internal guidelines should not replace physician documentation.
Facilities can work together with their medical staff to develop facility specific coding guidelines, which promote complete documentation needed for consistent code assignment. Additionally, these guidelines can guide the coding professionals as to when they should query physicians for clarification of their documentation. Any guidelines developed must be applied consistently to all records coded. An internal facility guideline should not interpret abnormal findings to replace physician documentation or physician query. The guideline may provide assistance in determining when a physician query is appropriate, but it may not interpret abnormal test results.
These facility guidelines must not conflict with the “Official ICD-10-CM Guidelines for Coding and Reporting” developed by the Cooperating Parties and, additionally, they should not be developed to replace the physician documentation needed to support code assignment.