The following topics have a place in your facility-specific coding guidelines:
Personal History – Does the facility capture personal history codes? These codes may be helpful to pass medical necessity edits. Include in your This week, I will conclude my discussion on developing facility-specific coding guidelines. Last week, we reviewed procedures, and this week, we will review diagnosis considerations.
First, all diagnoses that affect reimbursement, quality, or medical necessity should be reported. These diagnoses will determine how much the facility will be paid – as well as if it will be paid.
- guidance the role of the problem list.
- Family History – Document in your guidelines the coding of family history and if it is limited to specific subjects such as cardiovascular, cancer, or mental disorders.
- Status – It is possible to capture history of specific procedures such as coronary artery bypass grafts or pacemaker insertions. Another type of status is estrogen receptor status.
- Allergies – History of medication or environmental allergies are optional codes. Review this topic to determine if these codes will impact quality or reimbursement (such as risk adjustment).
- Long-Term Drug Use – Use of anticoagulants may impact medical necessity. Outline other codes to be captured under this topic.
- Smoking Status – This data may impact quality reporting. Include in your guidelines your definition of Z72.0 (tobacco use).
- Genetic History – This should include whether the patient is a carrier of a specific condition. These codes usually fall between Z14 – Z15.
- Social Determinants of Health (SDoH) – There has been much focus on this topic. The SDoH codes fall between Z55–Z65. Document which topics are to be coded and where to find the documentation for reporting the data.
- External Cause Codes – There are three specific field locators on the UB-04, but more may be reported. Document any state requirements that apply in your state.
Here are some other diagnosis topics to include in your facility guidelines: do-not-resuscitate (DNR) status, palliative care, body mass index, coma scale, and National Institutes of Health Stroke Scale (NIHSS). It is also important to explain which documentation the coder can use for diagnosis coding. For instance, a patient’s body mass index may vary while an inpatient. Which documentation will be the “source of truth” for coding the body mass index? The result of documented facility-specific coding guidelines is consistent data and easier-to-train contractors and new coders. The facility at large will benefit, as coding impacts reimbursement, quality, contracting, marketing, etc.
