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The official guidelines were updates. Here’s the changes you need to know.
The ICD-10-CM Official Guidelines for Coding and Reporting for fiscal year 2022 is out, detailing some coding and lanaguge changes. The full document can be found on the CMS website.
Below are the new and revised guidance, effective October 1, 2021.
General Coding Guideline Updates
Section I.B.13: Laterality
Under this section, the following paragraph is added:
When laterality is not documented by the patient’s provider, code assignment for the affected side may be based on medical record documentation from other clinicians. If there is conflicting medical record documentation regarding the affected side, the patient’s attending provider should be queried for clarification. Codes for “unspecified” side should rarely be used, such as when the documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification.
Section I.B.14: Documentation by Clinicians Other Than the Patient’s Provider
Clarification is added as to who can be considered a “clinician” and the diagnosis code exceptions, as follows:
There are a few exceptions when code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). In this context, “clinicians” other than the patient’s provider refer to healthcare professionals permitted, based on regulatory or accreditation requirements or internal hospital policies, to document in a patient’s official medical record.
These exceptions include codes for:
This information is typically, or may be, documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, pressure ulcer, or a condition classifiable to category F10, Alcohol related disorders) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification. The BMI, coma scale, NIHSS, blood alcohol level codes and codes for social determinants of health should only be reported as secondary diagnoses. See Section I.C.21.c.17 for additional information regarding coding social determinants of health.“
Section I.B.18Use of Sign/Symptom/Unspecified Codes
New to this section is the following paragraph:
As stated in the introductory section of these official coding guidelines, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.
Chapter-Specific Coding Guidance Updates
Chapter-specific updates to the ICD-10-CM guidelines include the following, based on chapter.
Section I.C.1.a.2.iHistory of HIV Managed by Medication
Further instruction is added to this guideline:
If a patient with documented history of HIV disease is currently managed on antiretroviral medications, assign code B20, Human immunodeficiency virus [HIV] disease. Code Z79.899, Other long term (current) drug therapy, may be assigned as an additional code to identify the long-term (current) use of antiretroviral medications.
This section also clarifies the following changes:
The BMI, coma scale, NIHSS, blood alcohol level codes and codes for social determinants of health should only be reported as secondary diagnoses.
Section I.C.1.g.1COVID-19 Infection (Infection Due to SARS-CoV-2)
COVID-19 guidelines have been slightly modified from their previous versions in these sections:
I.C.1.g.1.b Sequencing of codes
I.C.1.g.1.g Signs and symptoms without definitive diagnosis of COVID-19
I.C.1.g.1.j Follow-up visits after COVID-19 infection has resolved
I.C.1.g.1.l Multisystem Inflammatory Syndrome
I.C.1.g.1.m Post-COVID-19 Condition
Section I.C.2.sBreast Implant Associated Anaplastic Large Cell Lymphoma
This is a new section for FY 2022, and the following paragraph is added:
Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is a type of lymphoma that can develop around breast implants. Assign code C84.7A, Anaplastic large cell lymphoma, ALK-negative, breast, for BIA-ALCL. Do not assign a complication code from chapter 19.
Under Section I.C.4.a Diabetes Mellitus, some revisions include the addition of “injectable non-insulin antidiabetic” verbiage.There are also modifications to the following subsections:
Section I.C.4.a.3Diabetes mellitus and the use of insulin, oral hypoglycemics, and injectable non-insulin drugs
This section now includes the additions in bold:
Additional code(s) should be assigned from category Z79 to identify the long-term (current) use of insulin, oral hypoglycemic drugs, or injectable non-insulin antidiabetic, as follows:
If the patient is treated with both oral medications and insulin, both code Z79.4, Long term (current) use of insulin, and code Z79.84, Long term (current) use of oral hypoglycemic drugs, should be assigned.
Section I.C.4.a.6.a Secondary diabetes mellitus and the use of insulin, oral hypoglycemic drugs, or injectable non-insulin drugs
The same coding assignment instruction as I.C.4.a.3 is added.
Updates to this chapter, Section I.C.5.b Mental and Behavioral Disorders Due to Psychoactive Substance Use include slight wording modifications in the following subsections:
Section I.C.5.b.3 Psychoactive Substance Use, Unspecified
Minor grammatical changes are made.
Section I.C.5.b.4Medical Conditions Due to Psychoactive Substance Use, Abuse and Dependence
The section is new and includes information clarifying that medical conditions due to substance use, abuse, and dependence are not classified as substance-induced disorders.
Section I.C.5.b.5Blood Alcohol Level
Only one update is included:
A code from category Y90, Evidence of alcohol involvement determined by blood alcohol level, may be assigned when this information is documented and the patient’s provider has documented a condition classifiable to category F10, Alcohol related disorders. The blood alcohol level does not need to be documented by the patient’s provider in order for it to be coded.
Section I.C.12.a.2 Unstageable Pressure Ulcers
This guideline adds some additional coding information following debridement:
If during an encounter, the stage of an unstageable pressure ulcer is revealed after debridement, assign only the code for the stage revealed following debridement.
Under Section I.C.15.a General Rules for Obstetric Cases, there are a few additions under the sections below:
Section I.C.15.a.3 Final character for trimester
The following clarification (in bold) is added:
Whenever delivery occurs during the current admission, and there is an “in childbirth” option for the obstetric complication being coded, the “in childbirth” code should be assigned. When the classification does not provide an obstetric code with an “in childbirth” option, it is appropriate to assign a code describing the current trimester.
Section I.C.18.e Coma
Make sure to check out the subtle revisions to this section, such as new and modified wording and some reorganization. Key changes include:
New introductory statement that you can report code R40.20 Unspecified coma in conjunction with codes for any medical condition.
Section I.C.18.e.1 Coma Scale
This section was added and the remainder of the original guideline verbiage is moved under this new section. Here, the revised coma scale code parenthetical statement now reads (R40.21- to R40.24-).
Also, the following paragraph was added:
If multiple coma scores are captured within the first 24 hours after hospital admission, assign only the code for the score at the time of admission. ICD-10-CM does not classify coma scores that are reported after admission but less than 24 hours later.
Section I.C.19.d.6Burns and Corrosions Classified According to Extent of Body Surface Involved
ICD-10-CM modifies the wording of this guideline slightly:
Assign codes from category T31, Burns classified according to extent of body surface involved, or T32, Corrosions classified according to extent of body surface involved, for acute burns or corrosions when the site of the burn or corrosion is not specified or when there is a need for additional data. It is advisable to use category T31 as additional coding when needed to provide data for evaluating burn mortality, such as that needed by burn units. It is also advisable to use category T31 as an additional code for reporting purposes when there is mention of a third-degree burn involving 20 percent or more of the body surface. Codes from categories T31 and T32 should not be used for sequelae of burns or corrosions.
Section I.C.21 Factors Influencing Health Status and Contact With Health Services (Z00-Z99)
There are several updates to the guidelines in this chapter you should note. Key changes include:
The heading for this section was revised to include the emboldened text below:
Z Codes Indicate a Reason for an Encounter or Provide Additional Information about a Patient Encounter
Section I.C.21.c.4 History (of)
The following new paragraph as added:
The reason for the encounter (for example, screening or counseling) should be sequenced first and the appropriate personal and/or family history code(s) should be assigned as additional diagnos(es).
A new paragraph was added, which reads:
Code Z71.85, Encounter for immunization safety counseling, is to be used for counseling of the patient or caregiver regarding the safety of a vaccine. This code should not be used for the provision of general information regarding risks and potential side effects during routine encounters for the administration of vaccines.
I.C.21.c.17 Social Determinants of Health
The section was added to include further instruction of where social determinants of health codes can be located and that patient self-reported information can be coded.
Section I.C.22Codes for Special Purposes (U00-U85)
Added to the list of codes is U09.9 Post COVID-19 condition, unspecified, with an instruction to see Section I.C.1.g.1.m.
Renee Dowling is a billing and coding consultant with VEI Consulting in Indianapolis, Indiana.