New guides become effective Oct. 1, 2022.

It’s time to review the Official Guidelines for Coding and Reporting for fiscal year 2023. These take effect Oct. 1, 2022, and reflect the new ICD-10-CM codes as of that date. The changes are bolded so that the reader can distinguish what is newly added or edited.

Guideline I.A.19 (p. 12) has finally been updated to align more closely with what I have been saying for years (see my ICD10Monitor article from 1/22/19). The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists, and their statement is sufficient. The update says, however, “If there is conflicting medical record documentation, query the provider.” I would go further still. If there is cause to doubt the clinical validity, a query is indicated.

In I.B.14, underimmunization status joins Body Mass Index (BMI), pressure ulcer staging, coma and stroke scales, social determinants of health, laterality, and blood alcohol level, as elements of documentation which can be coded from non-provider documentation. Specifically, unvaccinated and partially vaccinated (i.e., underimmunized) for COVID-19 can be documented by others and picked up by the coder.

Guideline I.B.16. (p. 16) is trying to unravel the mess that Coding Clinic wrought in 2021, in the second quarter , when they advised use of a complication code of accidental puncture and laceration despite the clinician deeming it unavoidable and inherent to the procedure. The addition to the guideline states that the documentation must support that the condition is clinically significant, but the provider does not have to be explicit in calling it “a complication.” If the condition alters the course of the surgery as per the operative report, it is acceptable to capture that complication code. They still stipulate that if the documentation is not clear, a query is necessary.

I support this attempt to eliminate gaming of the system. Sometimes, even with the most superlative medical care, the best actions and intentions, stuff happens. It needs to be recorded and coded. If it triggers a PSI, so be it. However, I would not let the sole responsibility rest on the coder; when in doubt, query.

Hemolytic-uremic syndrome (HUS) is getting a new specific condition – D59.31, Infection-associated hemolytic-uremic syndrome. This is a condition which is brought on by an infection, but the mechanism is thrombotic microangiopathy (TMA). TMA is a clinical syndrome defined by hemolytic anemia, low platelets, and organ damage by tiny blood clots, specifically renal failure in HUS.

The guidelines specify in the case of HIV-related conditions and sepsis, if the reason for admission is this infection-associated HUS, it is sequenced as the principal diagnosis. For HIV-related disease, this makes more sense. The patient is being admitted because they have HUS, but there is a backdrop of HIV.

This is going to be tricker with sepsis. The precise wording is: If the reason for admission is hemolytic-uremic syndrome that is associated with sepsis, assign code D59.31, Infection-associated hemolytic-uremic syndrome, as the principal diagnosis. Codes for the underlying systemic infection and any other conditions (such as severe sepsis) should be assigned as secondary diagnoses. The verbiage seems to suggest that HUS should be sequenced first, but I believe that it is saying if the HUS is the reason for admission, then it would be sequenced first. Not IF the patient has HUS in the setting of sepsis, then you must sequence it first. It may very well be that the patient is being admitted for sepsis, and they just happen to have HUS as one of their acute sepsis-related organ dysfunctions. Then sepsis would still be the principal diagnosis. I submitted a request for clarification from the Centers for Disease Control and Prevention (CDC). I’ll let you know what they respond.

In the Neoplasm chapter, the guidelines clarify that the primary malignancy is sequenced as principal or first-listed diagnosis if it is “chiefly responsible for occasioning the patient admission/encounter and treatment is directed at the primary site.” Conversely, if treatment for a malignancy such as chemotherapy, immunotherapy, or radiation therapy is the reason for the admission, the Z51.- code would be principal/first-listed and the malignancy would be a secondary diagnosis. It has always been that way, but the new wording makes it crystal-clear now.

In I.C.2.t., the guidelines are clarifying a concept that clinically makes sense. Normally, a malignancy that spreads to a secondary site is found in C76-C80, Malignant neoplasms of ill-defined, other secondary and unspecified sites, subcategorized by site, such as lung or bone. If it is carcinoid, there is a separate subcategory of secondary neuroendocrine tumors. However, if a lymphoid cancer (e.g., lymphoma) spreads to a solid organ, the proper code to select has the final character of 9 which indicates extranodal and solid organ sites.

All the diabetes sections (general and gestational) had a revision clarifying that Z79.84, Long term use of oral hypoglycemic drugs is for use of oral hypoglycemic drugs, not just oral medications as previously indicated. The guidelines are introducing the new code of Z79.85, Long term (current) use of injectable non-insulin antidiabetic drugs to replace the generic other long term drug therapy in appropriate instances.

Dementia is undergoing a significant expansion indicating severity. Guideline I.C.5.d. reveals that if a patient is admitted at one severity and progresses, only the higher level is reported.

I.C.15.a.7) is a new paragraph stating that “In ICD-10-CM,” completed weeks of gestation refers to full weeks. I have no idea why this addition was necessary. In medicine in general, weeks of gestation always refers to completed weeks. That’s why you see “X weeks and Y days” or “X Y/7 weeks” documented – X weeks completed and Y days out of the next seven days which would indicate another completed week.

P. 68 gives us insight into how to approach complications after an elective abortion (conditions which are not going to be legislated away – in fact, they will likely increase). They give the example of the use of O04.6, Delayed or excessive hemorrhage following (induced) termination of pregnancy as opposed to O72.1, Other immediate postpartum hemorrhage. Post abortion is not considered postpartum. Similarly, if there is a complication, you wouldn’t use Z33.2, Encounter for elective termination of pregnancy. You either have an uncomplicated encounter or it is complicated; they are mutually exclusive and having a resultant complication, by definition, indicates that you had that procedure.

I.C.19.e.5)(c) spells out the fact that you don’t need there to be a change in the patient’s condition to assign or capture an underdosing code. If the patient took less than prescribed, even if no adverse effects were experienced, underdosing is still present and clinically significant. If there is a worsening or exacerbation of the condition, that would be another code.

I.C.21.c.10) brings up another new code, Z71.87, Encounter for pediatric-to-adult transition counseling. This can be used as a solo code or can be provided in addition to other conditions such as chronic conditions or another Z encounter code.

Finally, for Social Determinants of Health (SDoH), the guidance is that these codes are used only when there are problems arising from the SDoH or if it poses a risk. The example they offer is useful – not every individual living alone should be assigned Z60.2, Problems related to living alone. Another example would be Z56.1, Change of job. This might be a problem causing anxiety or depression warranting recording and coding, or it might be a welcome situation and not be considered an issue. For SDoH to impact medical decision making, the “diagnosis or treatment [needs to be] significantly limited by social determinants of health.”

As I do every year, I recommend you read the updated ICD-10-CM Guidelines yourself. It looks like there weren’t changes to the PCS guidelines.

Programming Note: Listen to Dr. Remer every Tuesday when she co-hosts Talk Ten Tuesdays with Chuck Buck, 10 Eastern.

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