Haugen Consulting Group has received questions regarding the 2024 update to the ICD-10-CM Official Guidelines for Coding and Reporting. This change added the terminology “clinically significant” in relation to reportable secondary diagnoses. In response to those questions, our team of coding professionals developed this Best Practice for reporting Clinically Significant Secondary Diagnoses. This document is current as of November 11, 2023.

For FY 2024, the ICD-10-CM coding guideline for reporting additional diagnoses was revised to include the term “clinically significant" when describing reportable secondary diagnoses. The revised Section III guideline is noted here with the revision in purple bolded text: 

Section III. Reporting Additional Diagnoses 

GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES 

For reporting purposes, the definition for “other diagnoses” is interpreted as additional clinically significant conditions that affect patient care in terms of requiring: 

• • clinical evaluation; or 
  • therapeutic treatment; or 
  • diagnostic procedures; or 
  • extended length of hospital stay; or 
  • increased nursing care and/or monitoring. 

The UHDDS item #11-b defines Other Diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.” UHDDS definitions apply to inpatients in acute care, short-term, long term care and psychiatric hospital setting. The UHDDS definitions are used by acute care short-term hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40. 

Since that time, the application of the UHDDS definitions has been expanded to include all non-outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc.). The UHDDS definitions also apply to hospice services (all levels of care). 

The following guidelines are to be applied in designating “other diagnoses” when neither the Alphabetic Index nor the Tabular List in ICD-10-CM provide direction. The listing of the diagnoses in the patient record is the responsibility of the provider. 

Guideline Review  

Official Coding Guideline (OCG) Section III 

A team of coding experts from Haugen Consulting Group has determined that the inclusion of this term does not change the intent of reporting additional diagnoses because the main portion of this guideline defines reportable diagnoses as those that require clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring. These bullet points can be summarized by the often-used MEAT acronym, in which a condition is reportable if it was: 

• • M: Monitored 
  • E: Evaluated 
  • A: Assessed, or 
  • T: Treated 

OCG I.C.16.a.6: Clinically Significant Diagnoses in Newborns 

It should be noted that there is a companion guideline for the Section III guideline in the chapter-specific guidelines for Chapter 16 (Certain Conditions Originating in the Perinatal Period) in Section I.C.16.a.6. This guideline had the term “clinically significant” included prior to FY 2024 and it is the opinion of HCG’s subject matter experts that the Section III guideline is being amended to match the newborn guideline. 

Code all clinically significant conditions 

All clinically significant conditions noted on routine newborn examination should be coded. A condition is clinically significant if it requires: 

• • clinical evaluation; or 
  • therapeutic treatment; or 
  • diagnostic procedures; or 
  • extended length of hospital stay; or 
  • increased nursing care and/or monitoring; or 
  • has implications for future health care needs 

Note: The perinatal guidelines listed above are the same as the general coding guidelines for “additional diagnoses,” except for the final point regarding implications for future health care needs. Codes should be assigned for conditions that have been specified by the provider as having implications for future health care needs. 

Use of the Entire Medical Record 

The ICD-10-CM Official Guidelines for Coding and Reporting states in more than one place that “The entire record should be reviewed to determine the specific reason for the encounter and conditions treated” (OCG page 1 and Section I.B.18). 

Additionally, the AHA’s Coding Handbook states the following about the medical record as a source document: 

The source document for coding and reporting diagnoses and procedures is the medical record. Although discharge diagnoses are usually recorded on the problem list, a final progress note, or the discharge summary, further review of the medical record is needed to ensure complete and accurate coding. Operations and procedures are frequently not listed on the face sheet or are not described in sufficient detail, making a review of operative reports, pathology reports, and other special reports imperative. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.1 

As such, if a condition is documented by the provider anywhere in the medical record and the condition meets MEAT criteria (i.e., the bullet points listed in the OCG as meeting the definition of a clinically significant diagnosis), the condition may be reported. For example, jaundice noted by the provider on a newborn physical examination with documentation that bili-lights were used may be reported as a secondary diagnosis because the condition was treated. However, if jaundice is diagnosed on physical exam with a note to monitor and no additional treatment was provided, the condition should not be coded. It is standard protocol to monitor newborns for jaundice and it should not be coded if it did not require increased monitoring (refer to the previously mentioned guideline I.C.16.a.6).  

Summary  

It is the opinion of Haugen’s coding professionals that satisfying one or more of the criteria outlined in OCGs III and I.C.16.a.6. translates to a clinically significant condition and that the addition of the term “clinically significant” in guideline III does not change the intent of the guideline or the way coders determine which secondary conditions to report. 

The future release of official coding advice from the Cooperating Parties (i.e., coding guidelines, Coding Clinic) that conflicts with this best practice supersedes the advice outlined in this document.