New ICD-10-CM Guidelines: Emphasis on SpecificityDozens of ICD-10-CM guidelines updates will go into effect on October 1st. Throughout the guidelines, there are many changes that will impact coding from a new call for specificity to revised instructions for coding social determinants of health. Pulled from Part B News by Decision Health here are the highlights from the new guidelines.

Decision Health has advised that we should expect auditors to get tougher on lax diagnosis coding. An instruction to code to “the highest level of specificity documented in the medical record” has been added to the Level of Detail in Coding subsection.

The guidelines use repetition to emphasize the importance of creating complete documentation and coding based on the entire medical record in the Use of Sign/Symptom/Unspecified Codes section.

A new paragraph reproduces an excerpt from the introduction to the guidelines:

    • “As stated in the introductory section of these official coding guidelines, a joint effort between the health care 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.”

Updates to the Laterality section remind clinicians and coders to pick a side — left, right or bilateral — when appropriate. New guidance states that codes for an unspecified side, such as M54.40 (Lumbago with sciatica, unspecified side) “should rarely be used,” and gives coders the freedom to look beyond the treating provider’s documentation if the information is incomplete.

    • “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,” the guidelines go further, instructing coders to ask the treating provider for clarification when there’s conflicting information in the note.

There are instances when an unspecified code is the only appropriate choice, but the updated guidance indicates that practices should use unspecified codes as a last resort, rather than a handy shortcut. The guidelines also clarify the definition of “other clinicians” in the Documentation by Clinicians Other than the Patient’s Provider section.

    • A clinician is any health care professional who is not the patient’s provider but who is “permitted, based on regulatory or accreditation requirements or internal hospital policies, to document in a patient’s official medical record.”

In addition, the new guidelines:

    • Add laterality and blood alcohol level to the list of diagnoses that can be coded based on documentation by “other clinicians.”
    • Instruct coders that blood alcohol level should only be reported as a secondary code.
    • Move information on self-reported SDOH to a new section in Chapter 21: Factors influencing health status and contact with health services (Z00-Z99).

Take note of two more changes to the general coding guidelines:

    • Dog bites withdrawn. The example W54.0- (Bitten by dog) is deleted from the subsection Other External Causes of Morbidity Code Issues.
    • Z code use clarified. Providing “additional information relevant to a patient encounter” is another reason to report Z codes, per the new guidelines

Additionally, there are ICD-10 Chapter specific guideline revisions that should be reviewed.

Chapter 1: Certain infectious and parasitic diseases (A00-B99), U07.1, U09.9

HIV Revisions:

    • A new subsection of the guidelines for human immunodeficiency virus (HIV) infection adds instructions on coding when the patient has a history of HIV managed by medication. Coders should select B20 (Humanimmunodeficiency virus [HIV] disease) and they may also report Z79.899 (Other long term [current] drug therapy) “as an additional code toidentify the long-term (current) use of antiretroviral medications.”
    • Additional updates to the HIV section of the guidelines remind coders that they should not report Z21 (Asymptomatic human immunodeficiency virus [HIV] infection status) based on documentation that the patient has “HIV disease.” When a patient is tested for HIV,associated high-risk behaviors should be documented “if applicable,” the new guidelines state.

COVID-19 Revisions:

    • The guidelines for COVID-19 contain several revisions based around new code U09.9 (Post COVID19 condition, unspecified). The guidelines instruct coders to “assign a code(s) for the specific symptom(s) or condition(s) related to the previous COVID-19 infection, if known, and code U09.9,” for sequela of COVID-19, or associated symptoms or conditions that develop after the patient has COVID-19.
    • Coders should not report U09.9 when a patient has an active COVID-19 infection, unless a patient has the misfortune to become reinfected with COVID-19 while they are experiencing conditions associated with a previous bout of COVID-19. In that event, the coder could report U07.1 (COVID-19) with U09.9, along with the codes that describe the effects of the current infection and the post-COVID conditions.
    • Coders should only report Z09 (Encounter for followup examination after completed treatment for conditions other than malignant neoplasm) and Z86.16 (Personal history of COVID-19) when a patient does not have “residual symptom(s) or condition(s),” the new guidelines state. In addition, when a patient with a history of COVID-19 develops multisystem inflammatory syndrome (M35.81), coders will report M35.81 and U09.9, effective Oct. 1. The current guidelines call for M35.81 and Z86.16.
    • You should also alert coders to the deletion of the instruction to report M35.81 and B94.8 (Sequelae of other specified infectious and parasitic diseases) when a patient has a history COVID-19 and develops multisystem inflammatory syndrome but the provider does not indicate the condition is due to the previous COVID-19 infection.

Chapter 2: Neoplasms (COO-D49)

    • Coders should report C84.7A (Anaplastic large cell lymphoma, ALK-negative, breast, for BIAALCL) for lymphoma associated with breast implants, a new subsection of the Neoplasm guidelines states. Coders should not assign a complication code from Chapter 19: Injury, poisoning and certain other consequences of external causes (S00-T88).

Chapter 4: Endocrine, nutritional and metabolic diseases (E00-E89)

    • New instructions for patients who are taking insulin and oral hypoglycemic drugs direct coders to report two codes: Z79.4 (Long term [current] use of insulin) and Z79.84 (Long term [current] use of oral hypoglycemic drugs), rather than Z79.4 alone. In addition, references to injectable non-insulin drugs and non-injectable noninsulin drugs have been added throughout the subsection.

Chapter 5: Mental, behavioral, and neurodevelopmental disorders (F01-F99)

    • Take note of two new instructions in this subsection.
      1. Medical conditions due to psychoactive substance use, abuse, and dependence. These conditions should not be reported as substance induced disorders. Coders should select a code for the medical condition and the appropriate psychoactive substance use code, the guidelines state, and give the example of a patient who has alcoholic pancreatitis due to alcohol dependence. The coder should select a code from the K85.2 (Alcohol induced acute pancreatitis) subcategory and the appropriate F10.2 (Alcohol dependence) code. “It would not be appropriate to assign code F10.288 (Alcohol dependence with other alcohol-induced disorder),” the new guidelines state.
      2. Blood alcohol level. Coders may select Y90 (Evidence of alcohol involvement determined by blood alcohol level) “when this information is documented and the patient’s provider has documented a condition classifiable to” an alcohol-related disorder (F10) code, the new guidelines state.
    • Coders should also be aware that the subsection Psychoactive Substance Use, Unspecified has been revised to state the codes should only be used when use of the psychoactive substance is associated with substance-related disorder or medical condition.

Chapter 12: Diseases of the skin and subcutaneous tissue (L00-L99)

    • A new paragraph for pressure ulcers instructs coders that, if “the stage of an unstageable pressure ulcer is revealed after debridement, they should assign only the code for the stage revealed following debridement.”

Chapter 15: Pregnancy, childbirth, and the puerperium (O00-O9A)

    • A revision to the subsection on selecting the final character for the trimester of pregnancy clarifies that coders may assign a code for the current trimester “when the classification does not provide an obstetric code with an ‘in childbirth’ option.”

Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

    • New guidance for coma scale codes will allow coders to report R40.20 (Unspecified coma) with codes “for any medical condition,” but codes R40.21- (Coma scale, eyes open) to R40.24- (Glasgow coma scale, total score) can be reported with codes for traumatic brain injury, the guidelines state.
    • When the chart contains multiple coma scores within 24 hours of the patient being admitted to the hospital, coders should only report the code “for the score at the time of admission” because “ICD-10-CM does not classify coma scores that are reported after admission but less than 24 hours later,” the new guidelines state.

Chapter 19: Injury, poisoning and certain other consequences of external causes (S00- T88)

    • Coders should not report the sequelae for burns or corrosions with codes from categories T31 (Burns classified according to extent of body surface involved) or T32 (Corrosions classified according to extent of body surface involved). The clarification reinforces the current instruction to report the burn or corrosion code with “7th character ‘S’ for sequela.”

Chapter 21: Factors influencing health status and contact with health services (Z00- Z99)

There are four areas in this section to take note of.

  • SDOH revisions:
    1. Coders need to be familiar with the SDOH codes (Z55-Z65) so they
      can follow the new instruction to code SDOH when it is

        • The new subsection for SDOH also lists the code categories and
          explains that coders may use social information provided by
          “other clinicians” that is included in the medical record, such as
          information from social workers, community health workers, case
          managers or nurses. The guideline on self-reported SDOH was
          relocated to this section and still carries the restriction that a
          clinician or the treating provider must sign off on the information
          and include it in the patient’s record.
    2. .Z71.85 (Encounter for immunization safety counseling):
        • This code should only be used “for counseling of the patient or
          caregiver regarding the safety of a vaccine,” not general
          discussions about the risks and possible side effects during a
          routine vaccination, the guidelines state.
    3. Use of history codes:
        • Coders should report history codes such as Z80 (Family history of
          primary malignant neoplasm) or Z91.81 (History of falling) after
          the code that indicates the reason for the encounter
    4.  Revision to Z53 (Donors of organs and tissues)
        • Z53 can now be utilized for self-donations of organs and tissues.
          Current guidelines restrict the use of Z52 to donations to other

Lastly, remember to check your local coverage determinations and payer policies for revisions based on the new guidelines. Those updates often come out with little warning.

ICD-10-CM Official Guidelines for Coding and Reporting FY 2022: www. 2022-icd-10-cm-coding-guidelines.pdf
ICD-10-CM Official Guidelines for Coding and Reporting FY 2021: coding-guidelines-updated-12162020.pdf