Well, the long-anticipated ICD-10-CM Official Coding and Reporting Guidelines for the 2017 fiscal year have been released, and there are definitely some key areas on which to focus. The Guidelines still are to be organized into sections. Section I includes the structure and conventions of the classification and general guidelines that apply to the entire classification, as well as chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. Section II includes guidelines for selection of principal diagnoses for non-outpatient settings. Section III includes guidelines for reporting additional diagnoses in non-outpatient settings. Section IV is for outpatient coding and reporting.

At the beginning of the guidelines there are instructions to help you identify the changes and revisions:

  1. Narrative changes appear in bold text
  2. Items underlined have been moved within the guidelines since the FY 2016 version
  3. Italics are used to indicate revisions to heading changes 

To help the reader, this article highlights some of these important changes and revisions. Within Section I there is the first new piece of guidance found in conventions (A) and in No. 12 excludes notes relating to the meaning of “excludes 1.” Although this guidance first was published back in October 2015, it now appears in the “official guidelines” and is to be applied when coding.

Excludes 1: A type 1 excludes note is a pure excludes note meaning “not coded here.” An excludes 1 note indicates that the code excluded should never be used at the same time as the code above the excludes 1 note. An excludes 1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

An exception to the excludes 1 definition is when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an excludes 1 note are related, query the provider. For example, code F45.8, Other somatoform disorders, has an excludes 1 note for “sleep-related teeth grinding (G47.63),” because “teeth grinding” is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding. However, psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and sleep-related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together. 

Next is the small wording addition found in guideline No. 13, Etiology/manifestation convention (“code first,” “use additional code,” and “in diseases classified elsewhere” notes)

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a “use additional code” note at the etiology code and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, with etiology followed by manifestation. 

Guideline No. 15 denotes the meaning and application of the word “with” – and this has some noteworthy new guidance.

The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the alphabetic index, or an instructional note in the tabular list.

The classification presumes a causal relationship between the two conditions linked by these terms in the alphabetic index or tabular list. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states that the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related.

Convention guideline No. 19 has also been added and reads as follows: Code assignment and Clinical Criteria: The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

General Coding Guidelines contain changes starting with item No. 13 relating to laterality. Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left side, right side, or both (bilateral). If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.

When a patient has a bilateral condition and each side is treated during separate encounters, assign the “bilateral” code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second treatment encounter, after one side has been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition at the previously treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate. 

General guideline No. 14 relates to Documentation for BMI, Depth of Non-Pressure Ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale, and there is some new wording added to clarify common clinical language and documentation within the health record.

For the body mass index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scaleand NIH Stroke Scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians other than the patient’s provider (i.e. a physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically 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, or pressure ulcer) 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 scaleand NIHSS codes should only be reported as secondary diagnoses.

The next change is within general guideline No. 16 for Documentation of Complications of Care: Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification if the complication is not clearly documented.

Within the Chapter-Specific Coding Guidelines there are several additions and revisions. The following are of particular interest, starting with Chapter 1, Certain Infectious and Parasitic Diseases (A00-B99), where we see “Zika virus infections guidance.”

Code only a confirmed diagnosis of Zika virus (A92.5, Zika virus disease) as documented by the provider. This is an exception to the hospital inpatient guideline Section II, H. 

In this context, “confirmation” does not require documentation of the type of test performed; the physician’s diagnostic statement that the condition is confirmed is sufficient. This code should be assigned regardless of the stated mode of transmission. 

If the provider documents “suspected,” “possible,” or “probable” Zika, do not assign code A92.5. Assign a code(s) explaining the reason for encounter (such as fever, rash, or joint pain) or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.

Within Chapter 4, Endocrine, Nutritional, and Metabolic Diseases (E00-E89), specific to diabetes mellitus coding: 

If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11, Type 2 diabetes mellitus, should be assignedCode Z79.4, Long-term (current) use of insulin, or Z79.84, Long-term (current) use of oral hypoglycemic drugs, should also be assigned to indicate that the patient uses insulin or hypoglycemic drugs. Code Z79.4 should not be assigned if insulin is given temporarily to bring a Type 2 patient’s blood sugar under control during an encounter.

Secondary diabetes mellitus and the use of insulin or hypoglycemic drugs: For patients who routinely use insulin or hypoglycemic drugs, Z79.4, Long-term (current) use of insulin, or Z79.84, Long-term (current) use of oral hypoglycemic drugs should also be assigned. Code Z79.4 should not be assigned if insulin is given temporarily to bring a patient’s blood sugar under control during an encounter. 

In Chapter 9, Diseases of the Circulatory System (I00-I99), you now see the following guidance:

The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term “with” in the alphabetic index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states that the conditions are unrelated.

For hypertension and conditions not specifically linked by relational terms such as “with,” “associated with,” or “due to” in the classification, provider documentation must link the conditions in order to code them as related. 

Hypertension with heart conditions classified to I50.- or I51.4-I51.9 is assigned to a code from category I11, Hypertensive heart disease. Use an additional code from category I50, Heart failure, to identify the type of heart failure in those patients with heart failure.

The same heart conditions (I50.-, I51.4-I51.9) with hypertension are coded separately if the provider has specifically documented a different cause. Sequence according to the circumstances of the admission/encounter.

This revision is significant, and a heavy emphasis should be taken in educating coding staff and providers in all healthcare settings and encounter types.

Also in this chapter-specific guideline is new language regarding hypertensive chronic kidney disease.        

For hypertensive chronic kidney disease assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. CKD should not be coded as hypertensive if the physician has specifically documented a different cause.

The last revisions I’ll bring to your attention within this article appear in Chapter 9.

Assign codes from combination category I13, Hypertensive heart and chronic kidney disease, when there is hypertension with both heart and kidney involvement. If heart failure is present, assign an additional code from category I50 to identify the type of heart failure.

Assign a code from category I16, Hypertensive crisis, for documented hypertensive urgency, hypertensive emergency, or unspecified hypertensive crisis. Also code any identified hypertensive disease (I10-I15). The sequencing is based on the reason for the encounter.

For coding professionals, it is necessary to review ALL sections of the guidelines to fully understand all of the rules and instructions needed to code properly.

Some action to take before Oct. 1, 2016 and after include the following:

  • Read the guidelines and make notes on the changes and revisions.
  • Discuss within your coding and clinical documentation improvement (CDI) staff and outline awareness steps.
  • Prepare and share information with your medical staff.
  • Develop coding reference tips.
  • Develop your coding educational material and have it include coding practice time of case scenarios.
  • Attend state and national coding educational offerings.
  • Read the American Health Association (AHA) Coding Clinic ICD-10-CM/PCS for the fourth quarter once it is released.
  • Plan for auditing or assessments of coding accuracy through the months of October-December.
  • Repeat education.
  • Repeat auditing and assessments.

Be sure to check out the American Health Information Management Association (AHIMA) education offerings and those from the California Health Information Association (CHIA), as they offer good opportunities to learn more about the changes.

Again, please review the guidance in total to fully understand the content and the impact to coding practices.

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