CIC (National Alliance) cheat sheet

The inpatient principal diagnosis is the condition established after study to be chiefly responsible for the admission, sequenced first per the ICD-10-CM Official Guidelines for Coding and Reporting.

UHDDS requires reporting all significant secondary diagnoses that affect treatment, length of stay, or resource use; abnormal findings alone are not reportable unless clinically significant.

The two-midnight rule generally supports inpatient admission when a physician orders it and the stay spans two midnights; shorter stays require documented exception criteria.

POA indicators are required for reported inpatient diagnoses; certain code categories are exempt from POA reporting, and non-POA conditions may affect severity and payment.

Coding Clinic is official AHA guidance for ICD-10-CM/PCS code assignment but does not establish payer coverage, medical necessity, or payment policy.

Physician queries must be nonleading, supported by clinical indicators, and documented in the record; verbal queries require authentication according to hospital policy.

The False Claims Act prohibits knowingly submitting false claims, including unsupported diagnoses, upcoded DRGs, and services not meeting medical necessity.

HIPAA requires minimum necessary use and disclosure of protected health information; de-identification under the Safe Harbor method removes 18 specified identifiers.

Code to the highest level of specificity supported by documentation; unspecified codes are assigned only when the record lacks detail for a more specific code.

When two conditions both meet principal diagnosis criteria, either may be sequenced first unless a coding guideline or payer rule specifies otherwise.

Combination codes capture both the underlying condition and its manifestation; sequence the underlying condition first when the guideline instructs.

For sepsis, assign the code for the systemic infection first, then the specific local infection; severe sepsis requires an additional code from R65.2- with organ dysfunction codes.

Hypertension with heart disease groups to I11.-; hypertension with chronic kidney disease groups to I12.-; both heart and kidney involvement groups to I13.-.

Diabetes with complications uses a single E10/E11 combination code that identifies the type and complication; additional manifestation codes are assigned only when instructed.

For secondary neoplasm admissions, code the secondary site first; code the primary site only when documented and relevant to the encounter.

Injury codes require a seventh character: A for initial encounter, D for subsequent encounter, and S for sequela; external cause codes are added when applicable.

Code signs and symptoms when no definitive diagnosis is documented; do not assign both a symptom code and a confirmed diagnosis code for the same condition.

ICD-10-PCS codes contain seven alphanumeric characters with no decimal: section, body system, root operation, body part, approach, device, and qualifier.

The root operation defines the objective of the procedure and is selected by comparing the procedure performed with PCS root operation definitions, not by the physician's terminology alone.

Excision cuts out a portion of a body part; resection cuts out all or a substantial portion, often requiring reconstruction or replacement.

Approach values include open, percutaneous, percutaneous endoscopic, via natural opening, via opening, and external; valid combinations are determined by the PCS table.

The device character identifies material or equipment used or left at the procedure site; character Z indicates no device.

Code each distinct root operation performed on a distinct body part; the same root operation on the same body part is coded once unless approach or device differs.

The PCS index and tables determine characters 4 through 7; the first three characters establish section, body system, and root operation.

Control of bleeding, drainage, extirpation, and extraction are distinct root operations with different definitions and are not interchangeable.

MS-DRG assignment uses the principal diagnosis, secondary diagnoses as CC or MCC, operating-room procedures, age, sex, and discharge disposition.

The principal diagnosis determines the major diagnostic category; surgical DRGs are generally assigned before medical DRGs when an operating-room procedure is coded.

A secondary diagnosis on the CC/MCC exclusion list for the principal diagnosis does not increase severity and may not change the DRG.

DRG payment equals the DRG relative weight multiplied by the hospital-adjusted base rate, with wage index, IME, DSH, transfer, and outlier adjustments.

Hospital-acquired conditions that are not present on admission may be excluded from CC/MCC severity and may reduce payment under HAC policies.

Certain transfers to post-acute care settings are paid on a per-diem basis rather than the full DRG payment.

Outlier payments may be made when the estimated cost of a case exceeds a threshold above the DRG payment.

DRG validation audits compare the coded principal diagnosis, secondary diagnoses, and procedures with the medical record to confirm DRG assignment.

Clinical validation confirms that a documented diagnosis is supported by clinical indicators, diagnostic findings, and treatment, not merely that a code matches documentation.

A compliant physician query presents clinical evidence and open-ended options without suggesting a diagnosis; yes/no queries require strong supporting evidence.

Audit samples may be random or stratified by service line, coder, DRG, or risk area; error rates equal records with errors divided by records reviewed.

Quality measures such as readmissions, patient safety indicators, healthcare-associated infections, and mortality use coded data for risk adjustment.

Risk adjustment uses diagnoses and procedures to account for patient severity and comorbidities when comparing provider outcomes.

Corrective action plans following audits specify root cause, education, monitoring, responsible parties, and timelines to prevent recurrence.

Documentation review should confirm physician authentication, timeliness, legibility, and linkage of diagnoses and procedures to medical necessity.

Coding quality benchmarks include accuracy rates, DRG change rates, query rates, and productivity measures tracked against internal or industry standards.

The inpatient principal diagnosis is the condition established after study to be chiefly responsible for the admission, sequenced first per the ICD-10-CM Official Guidelines for Coding and Reporting.

UHDDS requires reporting all significant secondary diagnoses that affect treatment, length of stay, or resource use; abnormal findings alone are not reportable unless clinically significant.

The two-midnight rule generally supports inpatient admission when a physician orders it and the stay spans two midnights; shorter stays require documented exception criteria.

POA indicators are required for reported inpatient diagnoses; certain code categories are exempt from POA reporting, and non-POA conditions may affect severity and payment.

Coding Clinic is official AHA guidance for ICD-10-CM/PCS code assignment but does not establish payer coverage, medical necessity, or payment policy.

Physician queries must be nonleading, supported by clinical indicators, and documented in the record; verbal queries require authentication according to hospital policy.

The False Claims Act prohibits knowingly submitting false claims, including unsupported diagnoses, upcoded DRGs, and services not meeting medical necessity.

HIPAA requires minimum necessary use and disclosure of protected health information; de-identification under the Safe Harbor method removes 18 specified identifiers.

Code to the highest level of specificity supported by documentation; unspecified codes are assigned only when the record lacks detail for a more specific code.

When two conditions both meet principal diagnosis criteria, either may be sequenced first unless a coding guideline or payer rule specifies otherwise.

Combination codes capture both the underlying condition and its manifestation; sequence the underlying condition first when the guideline instructs.

For sepsis, assign the code for the systemic infection first, then the specific local infection; severe sepsis requires an additional code from R65.2- with organ dysfunction codes.

Hypertension with heart disease groups to I11.-; hypertension with chronic kidney disease groups to I12.-; both heart and kidney involvement groups to I13.-.

Diabetes with complications uses a single E10/E11 combination code that identifies the type and complication; additional manifestation codes are assigned only when instructed.

For secondary neoplasm admissions, code the secondary site first; code the primary site only when documented and relevant to the encounter.

Injury codes require a seventh character: A for initial encounter, D for subsequent encounter, and S for sequela; external cause codes are added when applicable.

Code signs and symptoms when no definitive diagnosis is documented; do not assign both a symptom code and a confirmed diagnosis code for the same condition.

ICD-10-PCS codes contain seven alphanumeric characters with no decimal: section, body system, root operation, body part, approach, device, and qualifier.

The root operation defines the objective of the procedure and is selected by comparing the procedure performed with PCS root operation definitions, not by the physician's terminology alone.

Excision cuts out a portion of a body part; resection cuts out all or a substantial portion, often requiring reconstruction or replacement.

Approach values include open, percutaneous, percutaneous endoscopic, via natural opening, via opening, and external; valid combinations are determined by the PCS table.

The device character identifies material or equipment used or left at the procedure site; character Z indicates no device.

Code each distinct root operation performed on a distinct body part; the same root operation on the same body part is coded once unless approach or device differs.

The PCS index and tables determine characters 4 through 7; the first three characters establish section, body system, and root operation.

Control of bleeding, drainage, extirpation, and extraction are distinct root operations with different definitions and are not interchangeable.

MS-DRG assignment uses the principal diagnosis, secondary diagnoses as CC or MCC, operating-room procedures, age, sex, and discharge disposition.

The principal diagnosis determines the major diagnostic category; surgical DRGs are generally assigned before medical DRGs when an operating-room procedure is coded.

A secondary diagnosis on the CC/MCC exclusion list for the principal diagnosis does not increase severity and may not change the DRG.

DRG payment equals the DRG relative weight multiplied by the hospital-adjusted base rate, with wage index, IME, DSH, transfer, and outlier adjustments.

Hospital-acquired conditions that are not present on admission may be excluded from CC/MCC severity and may reduce payment under HAC policies.

Certain transfers to post-acute care settings are paid on a per-diem basis rather than the full DRG payment.

Outlier payments may be made when the estimated cost of a case exceeds a threshold above the DRG payment.

DRG validation audits compare the coded principal diagnosis, secondary diagnoses, and procedures with the medical record to confirm DRG assignment.

Clinical validation confirms that a documented diagnosis is supported by clinical indicators, diagnostic findings, and treatment, not merely that a code matches documentation.

A compliant physician query presents clinical evidence and open-ended options without suggesting a diagnosis; yes/no queries require strong supporting evidence.

Audit samples may be random or stratified by service line, coder, DRG, or risk area; error rates equal records with errors divided by records reviewed.

Quality measures such as readmissions, patient safety indicators, healthcare-associated infections, and mortality use coded data for risk adjustment.

Risk adjustment uses diagnoses and procedures to account for patient severity and comorbidities when comparing provider outcomes.

Corrective action plans following audits specify root cause, education, monitoring, responsible parties, and timelines to prevent recurrence.

Documentation review should confirm physician authentication, timeliness, legibility, and linkage of diagnoses and procedures to medical necessity.

Coding quality benchmarks include accuracy rates, DRG change rates, query rates, and productivity measures tracked against internal or industry standards.