AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2017 Quarter 4; Ask the Editor
Omitting ICD-10-CM Codes
Coding Clinic , Fourth Quarter 2016, page 149, states “A facility may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis”. Would it be appropriate for facilities to develop a policy to omit a diagnosis code based on the provider’s documentation not meeting established criteria? ...
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Article Overview
This article discusses facility-level handling of diagnosis documentation when provider charting does not align with internal clinical criteria. It focuses on documentation review, clarification processes, and the role of medical staff policies in ICD-10-CM coding workflow. The piece is relevant to coding professionals, CDI staff, compliance teams, and facility leadership responsible for diagnosis reporting practices.
Why This Topic Matters
Facilities need consistent, compliant approaches to reviewing diagnosis documentation without relying on automatic omission of codes. The article addresses a common operational and compliance issue that affects code reporting, provider communication, and documentation integrity.
What You Will Learn
- How facilities may approach diagnosis documentation review
- The role of clinical validation in coding workflow
- Why provider clarification processes matter for diagnosis reporting
- How facility policy and medical staff coordination relate to documentation practices
Who Should Read This
- Medical coders
- Clinical documentation integrity specialists
- Compliance staff
- Health information management professionals
- Facility administrators
- Medical staff leaders
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