This page addresses follow-up questions and additional information pertinent to our webinar
Special Coding Unit: Secondary Diagnosis Investigation

** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q: When a lab value like a dropping hemoglobin strongly suggests a condition such as acute blood loss anemia but the provider never documents it, what is the best practice for issuing a compliant query, and can we still query after the patient has been discharged?
A: Yes. A compliant query may be issued either concurrently or retrospectively after discharge, as long as it is non-leading, presents the relevant clinical indicators, and does not suggest a specific diagnosis or imply any financial impact. The query should ask the provider to clarify the clinical significance of the finding. If the provider does not respond or does not confirm the condition, it still cannot be coded from the clinical indicators alone. Partnering with CDI helps surface these query opportunities before the record is finalized.

Q: Our computer-assisted coding software automatically suggests diagnosis codes pulled from the problem list and medication list. How do we keep those tools from pushing us back toward over-coding the very conditions these guidelines tell us not to report?
A: Treat the tool’s output as prompts, not final codes. Every auto-suggested diagnosis still has to be validated against provider documentation showing the condition was monitored, evaluated, assessed, or treated on that encounter. Build a human review step into the workflow, reinforce with coders that a code appearing in the NLP output is not evidence of clinical significance, and give feedback to your vendor so the engine can be tuned to weight provider assessment over problem-list and medication-list mentions.

Q: If we correctly leave off a sign or symptom because a more definitive diagnosis is documented, and the payer then denies the claim for medical necessity, how do we reconcile following the coding guidelines with getting the claim paid?
A: The Official Coding Guidelines take priority, so we cannot add non-reportable codes just to secure payment. The better approach is to check the applicable LCD or LCA up front, identify which covered diagnoses are actually supported in the record, and report those. If a denial still occurs, appeal with the supporting documentation rather than back-coding symptoms. When a service genuinely will not be covered, that becomes an ABN and patient financial responsibility conversation, not a coding fix.

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