How to code "consistent with" conditions |
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Periodically, an official coding instruction “rocks the coding world.” Sometimes it’s just a small rumble, other times it’s more earth shattering. Most often it’s something between the two. But a recent clarification from the Central Office on ICD-9-CM that instructs coders that the expression “…consistent with…” is a phrase that indicates uncertainty and consequently cannot be coded from an ICD-9-CM standpoint is one of those instructions that probably rates rather high on the Richter Scale of coding quakes. The first official indication that the rule about not coding “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis” actually applies to other equivocal terms as well--besides just those five listed explicitly in the ICD-9-CM Official Guidelines for Coding and Reporting came in a letter from the Central Office on ICD-9-CM to CodeRyte, Inc. dated Oct. 8, 2003 in a response to a question posed by CodeRyte. (CodeRyte wanted to know whether “…consistent with…” and a few other frequently-used expressions were officially “equivocal” and so couldn’t be used for coding purposes.) Here is the key content from their Oct. 8, 2003 response:
As the Central Office on ICD-9-CM frequently does, this question and answer was ultimately reprinted for the masses about two years later in an issue of Coding Clinic for ICD-9-CM, published in September of 2005, specifically, the fourth quarter of 2005 issue (Volume 22, Number 3) on page 21:
It took another year, but the ICD-9-CM Official Guidelines for Coding and Reporting finally caught up with this official clarification and the Guidelines were revised accordingly. The most recent Guidelines (effective Nov.15, 2006) had a small but significant language change--from:
…to the slightly revised:
The addition of this new “…or other similar terms indicating uncertainty…” phrase following the Coding Clinic announcement that “consistent with” indicates an uncertain diagnosis is meant to convey that there are other unlisted terms of “uncertainty” (e.g. “consistent with”) that should not be coded; the list of “terms that indicate uncertainty” includes more terms and expressions than just the five that are explicitly mentioned—and presumably now includes those “terms that indicate uncertainty” as listed in the Third Quarter 2005 Coding Clinic for ICD-9-CM issue. These latest guidelines with the new “or other similar terms indicating uncertainty” language can be found at: http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide06.pdf (opens in a new window). The official September of 2005 clarification from Coding Clinic for ICD-9-CM supersedes any pre-September 2005 guidance to the contrary. For example, Coding Clinic for ICD-9-CM itself contains nine (9) examples where “consistent with” had been coded as if the condition exists (and which would now appear to be obsolete guidance):
Interestingly, the example presented in the first quarter 2000 issue was also reproduced years later in the Medicare Claims Processing Manual (Publication # 100-04) Chapter 23, Section 10.1.7 “Coding Questions and Answers for Diagnostic Tests.” So, folks can take great comfort that by relying on and further promulgating Coding Clinic's examples, CMS indirectly acknowledges the authority of the publishers of the universally accepted Coding Clinic for ICD-9-CM to clarify proper use of the ICD-9-CM code set in conjunction with the Official ICD-9-CM Guidelines for Coding and Reporting. (Since this section of the Medicare Claims Processing Manual uses an excerpt from the First Quarter 2000 issue of Coding Clinic for ICD-9-CM and so predates the far more recent September 2005 clarification, this section of the Medicare Claims Processing Manual will likely be revised in light of this “new” information. And, of course, any ICD-9-CM coding instructions issued by Medicare that contradict Coding Clinic for ICD-9-CM instructions would be applicable to Medicare claims only anyway.) The official September of 2005 clarification from Coding Clinic for ICD-9-CM also supersedes an oft-cited reference from the June 2005 issue of Pathology/Lab Coding Alert published by The Coding Institute. While some coding professionals and compliance consultants offered their advice in this June 2005 issue that “consistent with” conditions were reportable, their advice came before the official adjudication found in the September of 2005 clarification by Coding Clinic for ICD-9-CM and the advice of these consultants, although well-meaning at the time, should be considered out of date now. For what it’s worth, TriCare has now adopted this “‘consistent with’ cannot be coded” position as indicated in their audit findings available here: TRICARE Audit Document (opens in a new window) Also, remember that the coding for physicians (even services rendered to inpatients) always follows the Outpatient Coding Guidelines—as indicated in this Q & A (titled “Coding and Reporting for Physician’s Inpatient Care”) from the third quarter 2000 issue (Volume 17, Number 3) of Coding Clinic for ICD-9-CM (Pages 6-7):
It's important to remember that none of this limits in any way a provider's ability to use the phrase "consistent with" (or other similarly equivocal terms) in official clinical documentation. This remains a completely appropriate phrase and has its clinical value. Only the coding of the phrase (or non-coding of the phrase, in this case) has been clarified. Greg Schnitzer, CodeRyte, Inc. |