CIC (National Alliance) common mistakes
CIC · Understand the traps and how to avoid them.
Assigns the principal diagnosis from the admission history and physical, ED note, or 'admitting diagnosis' field and never reconciles it with the discharge summary and final diagnoses before closing the record.
Habit carried over from physician-office/outpatient coding, where the first-listed diagnosis is often the reason for the encounter; candidates also run short on time and lock in the first diagnosis they see.
What to do instead
Apply the UHDDS definition: the principal diagnosis is the condition established after study to be chiefly responsible for the admission. Read the discharge summary and final diagnoses last, then compare against the admission note; if the two conflict, query the provider before assigning.
Codes only the conditions printed on the discharge summary problem list and does not read progress notes, consult notes, operative reports, or lab/imaging results for additional documented conditions.
The problem list looks like a ready-made answer key and is faster to use; candidates underestimate how often acute renal failure, encephalopathy, severe malnutrition, or anemia are documented only in progress notes and never summarized.
What to do instead
Build a systematic record review: admission note, daily progress notes, consults, operative reports, discharge summary, and abnormal labs/imaging. Capture every condition that meets a coding guideline and is clinically supported, then verify it appears in the final diagnostic statement.
When documentation is ambiguous, conflicting, or non-specific (for example 'acute kidney injury' without stage or cause, 'sepsis' without a source, or 'altered mental status' versus encephalopathy), assigns a symptom code or a default diagnosis instead of sending a physician query.
Discomfort with querying, fear of appearing uninformed, and time pressure; candidates also do not recognize which ambiguities are clinically significant enough to warrant a query.
What to do instead
Use a compliant, non-leading query that cites the clinical indicators (vitals, labs, imaging) and offers clinically reasonable options plus 'other' and 'unable to determine.' Document the query and response, and code from the response only if it is clinically supported.
Chooses an ICD-10-PCS root operation by pattern-matching the procedure name (for example coding every 'excision of lesion' as Excision) without checking whether the surgeon removed the entire body part, only a portion, or used a different intent.
Root operations are the hardest part of PCS; candidates memorize a few common procedures and then apply the same root operation to procedures with different surgical intent.
What to do instead
Start from the root operation definitions and the intent of the procedure, not the procedure name. Ask: what was the objective-take out all of a body part (Resection), part of it (Excision), pull it out (Extraction), drain fluid (Drainage), or remove solid matter (Extirpation)? Then verify in the PCS tables.
Omits PCS codes for procedures documented only in the body of the operative report, or codes routine adjuncts such as irrigation and lavage, lysis of adhesions, or biopsy at the same site as the definitive resection.
Candidates code from a summary list of procedures and do not read the operative narrative; they also do not apply the PCS guideline that procedures integral to the definitive procedure are not coded separately.
What to do instead
Read every operative report completely and list each distinct procedure performed. Apply the PCS guidelines on integral procedures and code only significant, separately identifiable procedures; check that the code set matches the approach, device, and qualifier documented.
Predicts the DRG from memory or assumes a diagnosis is a CC or MCC without running the final coded set through the grouper, and does not verify which MDC the principal diagnosis drives.
The CC/MCC list and MDC logic are large and change yearly; candidates over-rely on the diagnosis wording ('severe' does not always mean MCC) and skip the grouper.
What to do instead
Always run the final codes through the official grouper and review the assigned MDC, DRG, and CC/MCC tier. Verify each secondary diagnosis is a valid CC/MCC for that principal diagnosis in that MDC, and recheck whenever a code is added or changed.
Sequences sepsis and a local infection with the local infection first, or codes sepsis without the severe sepsis and organ dysfunction codes when both are documented and meet the definition.
Candidates reason that the local infection caused the sepsis so it should lead, and they are unsure when organ dysfunction counts as sepsis-related versus a separate chronic condition.
What to do instead
Follow the sepsis sequencing guideline: code the systemic infection (sepsis, severe sepsis, or septic shock) first when it is the reason for admission, then the local infection, then any organ dysfunction. Query when it is unclear whether organ dysfunction is acute and sepsis-related.
Assigns the present-on-admission indicator 'Y' by default for every diagnosis, or leaves POA blank, without checking the admission note and timing of onset.
POA looks like a routine field and the documentation that establishes whether a condition was present at admission is buried in the admission history, nursing notes, and lab trends.
What to do instead
Determine POA for each diagnosis from the admission documentation and the timing of clinical indicators; use 'N' for conditions that develop during the stay, and 'U' only when documentation is insufficient. Remember POA status affects HAC reporting and quality outcomes, not just the claim.
Ignores 'code also', 'use additional code', 'code first', and combination-code instructions in the tabular list, producing a missing secondary code or an unbundled combination such as diabetes with a complication coded as two separate codes.
Candidates code from the alphabetic index only and do not confirm the entry against the tabular list, where the instructional notes live.
What to do instead
Always confirm every code in the tabular list and read the notes at the category, subcategory, and code level. Use combination codes where the classification provides them, and add any required additional codes in the order the notes specify.
Codes a 'rule out' or 'suspected' diagnosis as confirmed on an inpatient record, or fails to code a condition documented as 'probable,' 'likely,' or 'consistent with' that should be coded as if present.
Candidates mix inpatient and outpatient rules; outpatient coding prohibits coding rule-out diagnoses, while inpatient coding treats uncertain diagnoses as confirmed, and the two rules are easy to reverse.
What to do instead
For inpatient admissions, code a diagnosis documented as probable, suspected, likely, or consistent with as if it existed, and do not code a condition that is only being ruled out and is not documented as probable. When the record is contradictory, query.