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2016 ICD-10-CM Clinical Indicators

October 21, 2016

Section I (Conventions) of the 2017 ICD-10-CM Official Guidelines for Coding and Reporting includes a new guideline number 19 titled “Code assignment and Clinical Criteria”.  This guideline states “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

This has caused some concern in the industry, mainly due to reporting and auditing of the many quality programs currently in place and being planned for in the future. While this guideline puts in writing what is an age old process, current regulations, medical necessity requirements and audit programs negate this type of coding.

This issue brief is intended to provide supplemental information that may be useful as organizations determine how they will handle such situations.

FULL ISSUE BRIEF