Determining a facility’s coding guidelines is the top priority for every coding professional who begins working at a new organization. While most facilities have specific coding guidelines, they’re usually undocumented. As a result, new coding professionals are usually left with no choice but to learn about the facility guidelines by talking with the tenured coding staff. This approach can cause several problems. First, not everyone remembers the facility guidelines. Second, guideline information that’s shared through conversations can vary from individual to individual, which can be especially confusing to a newly hired coding professional. This informal, word-of-mouth explanation process is essentially like the game of telephone, where each player relays a message shared by the previous player by whispering a phrase into the next player’s ear. The phrase passes through a chain of players, with the final person often hearing a completely different word than the one the first player shared. And finally, information may become outdated due to the lack of annual review, with guidelines subject to individual interpretation.
Coding professionals should keep in mind that the primary purpose of the health record is as a tool for communication between care providers and care planning; use of the record for coding/compliance purposes is secondary. Balance must be achieved. For example, code descriptions in classifications do not necessarily reflect how terms are used between care providers.
Facility-specific coding guidelines are necessary for training new coding professionals, collecting consistent data, and tracking the changes of data collection from year to year. The best practice for facility-specific coding guidelines is to put them in writing. These guidelines should then be reviewed on an annual basis and updated for changes to each code set. This Practice Brief can be used to walk through various diagnoses and procedure considerations to assist organizations to develop robust facility-specific coding guidelines. The Practice Brief includes basic guidance as well as insights into the preparation and decision-making process. It also includes suggestions for specific diagnosis and potential procedure coding topics.
An Excel tool was developed in conjunction with this Practice Brief, which includes instructions for developing facility-specific coding guidelines. The Practical Application tab of the tool includes a real-life example of one large teaching facility using the tool and Practice Brief to develop its own facility-specific coding guidelines.
The ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting, American Hospital Association’s (AHA’s) Coding Clinic for ICD-9-CM and ICD-10-CM/PCS, and the American Medical Association’s (AMA’s) CPT Assistant are considered the official coding resources for coding professionals. These references can be used to respond to coding audits and claim denials. The Official Coding Guidelines are published annually; the ICD-10-CM document is published by the Centers for Disease Control and Prevention (CDC) and the ICD-10-PCS document is published by the Centers for Medicare and Medicaid Services (CMS). Coding Clinic issues are published quarterly, and CPT Assistant is published monthly. The hierarchy of the official resources is the classification/conventions themselves, followed by the ICD-10-CM/PCS Official Guidelines for Coding and Reporting, then Coding Clinic and CPT Assistant. It is important for facilities to follow the official guidance, and facility-specific coding guidelines must not conflict with the official resources.
The official guidance supports the development of facility-specific coding guidelines. According to Coding Clinic, “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.”1 Subsequent publications of Coding Clinic include articles that emphasize that facility-specific guidelines must not conflict with the Official Coding Guidelines2 and address the inappropriateness of inserting the interpretation of abnormal laboratory values and substituting clinical documentation to support diagnoses.3 The facility-specific guidelines support consistent coding at the organization; they do not substitute for clinical documentation of services and conditions.
Coding professionals should assign codes for principal or first-listed diagnosis codes and all secondary conditions that meet the definition of reportable conditions. Procedures assigned by the coding professional for inpatient and outpatient records should be clearly defined. For inpatient coding, the coding professional should assign procedure codes for all procedures that impact reimbursement and quality reporting, and ensure data is captured to meet the organization’s needs as designated by the facility guidelines. For outpatient coding, the guidelines should outline which procedures are assigned procedure codes by the coding professional as many outpatient procedure codes are assigned via the charge description master (CDM). The guidelines should define which documentation is appropriate to use for code assignment (for example, whether the coding professional can code from the Pre-Anesthesia Evaluation or Problem List). The guidelines should also provide support for querying the physician when the documentation is unclear.
The facility-specific coding guidelines should not duplicate information found in the ICD-10-CM/PCS Official Guidelines for Coding and Reporting, Coding Clinic, or CPT Assistant.
The facility guidelines should document the maximum number of diagnoses/procedures to be reported; this number could change as billing and abstracting systems are changed and regulations are updated. Each version of the document should be maintained so that chart audits can be matched to the version that is applicable to that time period. The facility guidelines will be a living document that will require ongoing maintenance. At a minimum, the facility guidelines should be reviewed annually for updates based on changes in the code sets.
Preparation and Required Information/Decisions
Successful facility-specific guideline creation requires preparation. Key decisions must be made during the preparation period. There are several topics to review and finalize prior to writing the guidelines. A collaborative approach, inclusive of all relevant hospital departments, is recommended—decisions should not be made by the coding manager alone.
It is important to understand the data needs of the organization in order to formulate useful guidance. Interviews with marketing, administration, information services, patient financial services (PFS), case management, medical staff office, cancer registry, quality/performance improvement, and other staff will help identify data needs. For example, the cancer registry may generate reports on patients who have a cancer diagnosis or history of a cancer diagnosis and have been at the hospital in the previous year. Capturing the diagnosis code for patients who have a personal history of cancer is helpful for the cancer registry to perform annual follow-ups.
In addition, the state may have a state data commission, which includes specific guidelines on what information is reported to the state. For example, the reporting of the external cause codes is frequently regulated. Determine if your state has a state data commission and identify any requirements.
It is important to determine if additional regulatory requirements should be addressed. Review other regulatory statutes that may impact reimbursement such as hospital-acquired conditions (HAC), quality reporting, the Hospital Readmissions Reduction Program, hierarchical condition categories (HCCs), and the Promoting Interoperabilty program. These regulations impact conditions and procedures that should be coded. The regulations may indicate grouper versions (such as the state Workman’s Compensation Program) and whether APR-DRGs or MS-DRGs are used (e.g., Maryland is a waivered state and all payers use APR-DRGs). Participation in Alternative Payment Models (APMs) may also impact the codes that are assigned. Ambulatory Payment Classifications (APCs) and Ambulatory Payment Groups (APGs) are two potential reimbursement methodologies that would be used for outpatient care. On the physician side, capturing chronic care management and annual visit services can significantly impact the practice’s reimbursement. Telehealth, a service newly covered by CMS, is another discipline that requires codes.
A review of the third-party contracts with finance or PFS staff will help determine if any payer has specific coding requirements such as CPT versus the Healthcare Common Procedure Coding System (HCPCS), the reporting of modifiers (-50 versus -RT/-LT), or use of external cause codes. The inpatient grouper type and version for inpatient reimbursement should be documented as well as the method for outpatient reimbursement. The facility may have a payer matrix and this information may be captured in that document.
Guidelines should be developed by patient type such as inpatient, outpatient, home health, or inpatient rehabilitation, as their requirements vary. Developing separate guidelines by patient type will facilitate ongoing maintenance.
Healthcare claims reporting and formats should also be explored. The field locator (FL70) or abstract field “Reason for Visit” has three spaces on the UB-04 (institutional claim type). These field locators can be used to collect signs and symptoms which assist with meeting medical necessity. Determine who will collect this information (e.g., patient access or coding staff) and if you collect up to the maximum of three. It is important to remember that “Admit Diagnosis” is a separate field.
Facility-specific guidelines also impact coding compliance. A policy for clinical validation should be documented in collaboration with the compliance department. This policy would address the process to resolve clinical documentation conflicts within the health record. It should specifically address situations where the coding professionals and/or clinical documentation staff feel that clinical validation (e.g., test results) do not support a physician’s diagnostic statement. This situation may arise between quality and coding staff.
Query documentation may be included in the legal record or may be filed separately. This should be specified in the facility-specific guidelines. If it is filed separately, the physician would document the response to the query in the clinical documentation as an addendum.
Some facilities assign ICD-10-PCS codes on outpatient cases, though such codes are not reported on healthcare claims for outpatient services. Remember that the Health Information Portability and Accountability Act (HIPAA) transaction standards designate ICD-10-PCS codes as the standard for reporting inpatient procedures only.4 If a facility decides to capture ICD-10-PCS on outpatient services, the facility’s guidelines should document this decision and the rationale. As requirements change, this decision may change as well.
For outpatients, the assignment of CPT and HCPCS codes can be accomplished using different methods. The coding professional can assign CPT/HCPCS codes or these codes can be assigned automatically via the chargemaster. The facility guidelines should specify which CPT/HCPCS codes are assigned manually by a coding professional and how the billing system determines where the code is generated. The determination may be based on revenue code or some other mechanism specific to the facility’s billing software. A best practice is to assign a code either via the chargemaster or by a coding professional but not both. If procedure codes are assigned by both the chargemaster and coding professional and reported on the claim, it could lead to billing and reimbursement errors.
Other topics specific to outpatients that should be addressed in facility guidelines are the use of unlisted CPT codes or “Inpatient Only” procedures performed on outpatients. The facility guidelines should address any additional steps that the coding professional should perform when either situation arises. For example, if the coding professional assigns a total hip replacement CPT code on an outpatient and encounters the Inpatient Only procedure edit, what action is the coding professional expected to take? Does the coding professional verify that the patient is an outpatient? Should they notify someone? It is better to resolve these situations prior to dropping the claim. Similarly, unlisted procedures may also require action. The unlisted CPT codes typically require a copy of the procedure note to be provided to the payer for review. Facility guidelines might specify, for example, that the coding professional review again the procedure notes for complete documentation or have another coding professional review the coding to ensure the assignment of an unlisted code is correct.
Specific Diagnosis Topics
Before making decisions on diagnosis coding policies, review lists of diagnoses that would impact reimbursement. Document the reason/purpose for collecting each of the topics. When the purpose or reason changes, the decision regarding the data may need to change as well. The facility guidelines should also specify where the documentation is in the patient health record (either paper, hybrid, or electronic) to ensure data is collected consistently for the topic.
The capture of personal history codes is a facility preference. A best practice is to determine if there are specific specialties, such as oncology, that utilize the data. Specific requirements should be documented. In some cases, the codes are helpful for passing medical necessity edits. In this section of the guidelines, we discuss how the facility or organization utilizes the problem list and who is responsible for maintaining the problem list (e.g., physician only).
The capture of family history information may vary based on patient context or specific medical specialties; for example, family history of cardiovascular disorders or cardiac sudden death captured for patients who present with a myocardial infarction. A best practice is to document expectations for coding and reporting family history and to include specific examples.
The status codes describe a history of a procedure (e.g., amputation) or the presence of a medical implanted device (e.g., pacemaker). These codes are optional. For example, estrogen receptor status (Z17.-) may be captured with breast cancer (C50.-).
A patient’s history of environmental and medication allergies may impact treatment. Review allergies to determine if these codes impact reimbursement or quality reporting. Define certain medications or situations when the allergy codes are assigned. It is important to determine if the allergy information may be collected and reported using other methods.
Long-Term Drug Use
Define if the coding professional should assign long-term drug use codes. In some situations (e.g., use of anticoagulants), the code may be useful to meet medical necessity requirements.
Smoking/vaping status is a high-profile topic. There continues to be a great deal of research on the effect of smoking on health. The one specific code that should be addressed in the guidelines is Z72.0 (Tobacco Use). Smoker is indexed to F17.2- for nicotine dependence. The use of Z72.0 should be defined for your organization (e.g., a social smoker).
Genetic susceptibility (Z14-Z15) may be helpful for medical necessity. For example, the code indicating that a patient is a carrier of a condition may clarify the need for testing.
Social Determinants of Health
Social determinants of health (SDOH) includes social factors that may influence a patient’s access to healthcare. The prevailing assumption is that if the social factors are addressed, then the patient’s need for healthcare may decrease or that community services may be provided. These factors are found in the code range Z55 – Z65 in ICD-10-CM. As there are no definitions for these codes, it is currently recommended that facilities develop their own internal definitions. These conditions may impact reimbursement in the future. Coding professionals can code this information for population health needs as well as to be proactive for any reimbursement ramifications.
External Cause Codes
The four types of external cause codes are how the accident happened, the place of occurrence, activity, and external cause status. These codes may be required by the state data commission or third-party payers. Determine the situations that the state requires for external cause reporting and which external cause codes are required. If there is a statewide trauma registry, some external cause codes will be required. The guidelines should also address if the external cause codes are required on every visit or only the initial visit (per the ICD-10-CM Official Guidelines for Coding and Reporting). Some state database commissions require the reporting for each visit that a traumatic injury/poisoning is treated.
Do Not Resuscitate
Do Not Resuscitate (DNR) is a status code that is optional. This data may be used to explain changes in mortality levels for specific services.
Palliative Care is a required code for hospice reimbursement but may be reported for other patient types. The code explains that the patient was placed on comfort measures. Also, it is best to report the code in the top ten positions to ensure that it will be considered by the third-party payer when the claim is processed.
Identify documentation that may be used to capture body mass index (BMI), pressure ulcer stage, SDOH, coma scale, National Institute of Health Stroke Scale (NIHSS), and depth of non-pressure ulcers. This direction will result in consistency among the coding and clinical documentation staff.
Specific Procedure Topics
There are several issues to consider on specific procedure codes. The facility guidelines should document which practitioner types may perform procedures (e.g., physicians, chiropractors, physician assistants, nurse practitioners, midwives, podiatrists, dentists, etc.) and the frequency (e.g., initial midline, every PICC line, etc.). It is important to provide specifics regarding the type of documentation used for procedure coding such as bedside procedures and radiology tests.
Computer/Robotic Assisted Procedures
Computer/robotic assisted procedures are captured differently depending on whether the patient is an inpatient or outpatient. For inpatients, the ICD-10-PCS code assigned for the procedure performed includes the method. For outpatients, the method may be included in either the CPT/HCPCS code or a separate HCPCS code. Determine if coding professionals should assign S2900 (Surgical techniques requiring use of robotic surgical system) or if this code is assigned via the chargemaster. Another option is that the computer/robotic assistance information is not needed. This information could be used to compare the response to procedures performed with and without computer/robotic.
Separate guidelines are needed for coding interventional radiology procedures for inpatients and outpatients. For inpatients, determine if radiology guidance will be coded with ICD-10-PCS codes and if so, document the rationale for including the guidance. For outpatients, determine which procedures require the additional CPT code for radiology guidance. Many of the CPT codes include radiologic guidance and separate reporting is not appropriate. Document how the determination is made if the code is assigned manually by a coding professional or via the chargemaster.
There are ICD-10-PCS and CPT codes for radiology procedures including X-rays, CT, MRI, nuclear medicine, PET scans, and ultrasound. Document which of these codes are assigned for inpatients and which are assigned for outpatients. Also, include the rationale for capturing radiology codes, as they are statistically captured through the chargemaster for inpatients and outpatients.
Some neurology procedures may be captured, including electroencephalogram, video-monitoring, intraoperative monitoring, and electromyogram. Document which procedures are coded for which patient types.
If the facility performs radiation therapy and/or chemotherapy, document how these services are captured. The range of services for radiation and chemotherapy should be included in the facility-specific coding guidelines.
Review payer contracts to determine if any payer reimburses based on the rehabilitation MS-DRGs. If so, at least one physical therapy (PT)/occupational therapy (OT) service must be coded for the rehabilitation MS-DRG to be assigned accurately. Document which service should be coded and what documentation is used to assign the correct code.
These services are coded either via the chargemaster or a coding professional for outpatients. Whichever method is used should be documented in the guidelines. Review the available clinical documentation to verify that start and stop times as well as the type of injection/infusion are clearly documented. The guidelines should include where to locate the clinical documentation for start/stop times.
Osteopathic Manipulation Therapy
If the facility is an accredited osteopathic organization, it is important to capture the osteopathic manipulation therapy (OMT). These services are performed by a doctor of osteopathy (DO). The OMT volume is needed to complete the accreditation questionnaire. If the facility is not an accredited osteopathic organization, then document if the procedures should be coded. The services can be captured using ICD-10-PCS for inpatient or CPT for outpatient.
Chiropractic treatment is performed in hospitals. Discuss the need for capturing the information as it currently does not impact the hospital’s reimbursement. If the decision is made to capture the services, document the rationale (for example, this may include physician re-credentialing).
A limited number of obstetrical procedures that do not impact reimbursement, such as the insertion of the epidural catheter, external fetal monitor, internal fetal monitor, artificial rupture of membranes (AROM), methods of labor induction, and the placement of the electrode on the scalp, can be coded. Document if these procedures should be coded. For newborns, document if hearing tests, circumcisions, and vaccinations are captured as procedures.
If the facility offers substance abuse services, document if detoxification or counseling sessions should be coded using ICD-10-PCS for inpatients and CPT for outpatients. The outpatient codes may be assigned via the chargemaster. If the technical fees are not charged, the information should indicate that health information management (HIM) staff codes these services.
Transfusion information is typically collected in the blood bank or the laboratory. If HIM staff is required to assign the transfusion procedure code for inpatients or outpatients, the guidelines should indicate which patient type is coded.
Peripherally inserted central catheter (PICC) lines are included in the HACs, so HIM staff should code these procedures to be included in the quality scores. Clarify if the exchange of lines is coded and how the codes are reported. Remember that the removal of lines is not a codable procedure.
Midline catheters do not impact reimbursement or HACs. The guidelines should identify if these procedures are coded.
Determine if the insertion of the umbilical line impacts reimbursement. Identify if these procedures are coded in the guidelines.
Cardiopulmonary resuscitation (CPR) is a procedure that may be performed for either an inpatient or outpatient. Document if the procedure should be captured.
Oral Medications (Beyond New Technology)
Beyond new technology add-on payments, oral medication administration is typically captured through the pharmacy chargemaster. If the facility requires assignment of PCS codes for oral administration of medications, document the specific drugs to be captured.
Other Ancillary Procedures
Document other ancillary procedures (e.g., ECGs) that need to be captured at the facility. Include the reasoning for capturing the data and the location within the clinical documentation for the procedure.
Another item to include in the facility-specific coding guidelines is the discharge status. Identify who is responsible for assigning/verifying the status and which documentation is utilized to establish this data element. Discharge status may be assigned by HIM or another department and then verified by HIM. Another consideration is the process of handling discharge statuses that change based on patient actions. For example, a patient is discharged to home without home health, but home health is ordered and received within three days of discharge. The payer will notify the organization that the discharge status should be updated. The guidelines may address if only the billing database is amended or if HIM should update the abstract.
Another consideration to include in the facility-specific coding guidelines is abstracting information. Items include attending physician, performing physician (surgeon), and consulting physicians if they are collected. This information may be reported on the claim but may also be collected for other reasons. x
American Hospital Association. Coding Clinic for ICD-10-CM and ICD-10-PCS, First Quarter 2000, p. 4.
American Hospital Association. Coding Clinic for ICD-10-CM and ICD-10-PCS, Second Quarter 2004, p. 14.
American Hospital Association. Coding Clinic for ICD-10-CM and ICD-10-PCS, First Quarter 2014, p. 15-16.
Centers for Medicare and Medicaid Services. Code Sets Overview. https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Code-Sets/index.html.
Centers for Disease Control and Prevention. ICD-10-CM Official Guidelines for Coding and Reporting FY 2019. https://www.cdc.gov/nchs/icd/icd10cm.htm.
Centers for Medicare and Medicaid Services. ICD-10-PCS Official Guidelines for Coding and Reporting FY 2019. https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-PCS.html.
American Hospital Association. Coding Clinic for ICD-10-CM and ICD-10-PCS. http://www.ahacentraloffice.org/codes/products.shtml#CodingClinic.
American Medical Association. CPT Assistant. https://commerce.ama-assn.org/store/ui.
Laurie M. Johnson, MS, RHIA, FAHIMA
Angela Rickard, CCS
Patricia Buttner, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS, CICA
Margaret Foley, RHIA, CCS, PhD
Patricia Buttner, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS, CICA
Margaret Foley, RHIA, CCS, PhD
Sharilyn Kmech, CHIM
Melissa Potts, RN, BSN, CCDS, CDIP
Mary H. Stanfill, RHIA, CCS, CCS-P, MBI, FAHIMA
Donna Rugg, RHIT, CDIP, CCS-P, CICA, CCS