by Angela Lehoux, CCS
Instructor, Libman Education
I’ve been a coder for a long time and one thing is for sure: “grey areas” in coding are sometimes unavoidable. Although, I do not have a concrete answer in how to handle these areas of grey matter, I do have some advice to share.
First, when confronted with a “grey” situation, that is, a situation where the accurate and appropriate coding is not clear, be sure you have followed the instructions and conventions of the classification system. Consult the book, whether it is online or a physical one. There may be just one little instructional note hiding under the category or block that could clarify the whole situation for you. Sometimes the answer to your question will be within these pages.
Second, consult the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting. On the first page of the guidelines we are instructed: “The instructions and conventions of the classification take precedence over guidelines.” Therefore the guidelines are the next place to look. Is there a relevant chapter specific guideline? Remember, there is too much information for us to memorize. Be familiar with the topics and know where to find the information.
Third, consult Coding Clinic. Notice, Coding Clinic, which offers advice on the coding of specific scenarios sent in by readers, is not the first place to go for clarity. According to the American Hospital Association, publisher of Coding Clinic, “Coding Clinic is to be used as an official resource when the classification and the guidelines do not provide direction.” Therefore conventions and guidelines of the classification system must be consulted and followed first. Then, if you are still stuck, move to Coding Clinic.
Fourth, if there are no relevant instructions, no guidance from the guidelines, no advice from Coding Clinic that matches your situation, or any of these appear to conflict, it is time to use your grey matter. Huddle together as a coding team at your facility, review the options, and make an educated and reasonable decision. Be sure to document why you are choosing to code it the way you do and stay consistent as a team.
Coding is not an easy job and it certainly is not black and white, even though it was intended to be that way. Instead, there are many grey areas and you and I must do the best we can to accurately reflect the patient’s story.
So, come on, we got this! We’re coders and still Hang’n 10!
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