Updates to the ICD-10-CM Official Guidelines for Coding and ...

New guides become effective Oct. 1, 2022. It's time to review the Official Guidelines for Coding and Reporting for fiscal year 2023. 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It’stimetoreviewtheOfficialGuidelinesforCodingandReportingforfiscalyear2023.ThesetakeeffectOct.1,2022,andreflectthenewICD-10-CMcodesasofthatdate.Thechangesareboldedsothatthereadercandistinguishwhatisnewlyaddedoredited. GuidelineI.A.19(p.12)hasfinallybeenupdatedtoalignmorecloselywithwhatIhavebeensayingforyears(seemyICD10Monitorarticlefrom1/22/19).Theassignmentofadiagnosiscodeisbasedontheprovider’sdiagnosticstatementthattheconditionexists,andtheirstatementissufficient.Theupdatesays,however,“Ifthereisconflictingmedicalrecorddocumentation,querytheprovider.”Iwouldgofurtherstill.Ifthereiscausetodoubttheclinicalvalidity,aqueryisindicated. InI.B.14,underimmunizationstatusjoinsBodyMassIndex(BMI),pressureulcerstaging,comaandstrokescales,socialdeterminantsofhealth,laterality,andbloodalcohollevel,aselementsofdocumentationwhichcanbecodedfromnon-providerdocumentation.Specifically,unvaccinatedandpartiallyvaccinated(i.e.,underimmunized)forCOVID-19canbedocumentedbyothersandpickedupbythecoder. GuidelineI.B.16.(p.16)istryingtounravelthemessthatCodingClinicwroughtin2021,inthesecondquarter,whentheyadviseduseofacomplicationcodeofaccidentalpunctureandlacerationdespitethecliniciandeemingitunavoidableandinherenttotheprocedure.Theadditiontotheguidelinestatesthatthedocumentationmustsupportthattheconditionisclinicallysignificant,buttheproviderdoesnothavetobeexplicitincallingit“acomplication.”Iftheconditionaltersthecourseofthesurgeryaspertheoperativereport,itisacceptabletocapturethatcomplicationcode.Theystillstipulatethatifthedocumentationisnotclear,aqueryisnecessary. Isupportthisattempttoeliminategamingofthesystem.Sometimes,evenwiththemostsuperlativemedicalcare,thebestactionsandintentions,stuffhappens.Itneedstoberecordedandcoded.IfittriggersaPSI,sobeit.However,Iwouldnotletthesoleresponsibilityrestonthecoder;whenindoubt,query. Hemolytic-uremicsyndrome(HUS)isgettinganewspecificcondition–D59.31,Infection-associatedhemolytic-uremicsyndrome.Thisisaconditionwhichisbroughtonbyaninfection,butthemechanismisthromboticmicroangiopathy(TMA).TMAisaclinicalsyndromedefinedbyhemolyticanemia,lowplatelets,andorgandamagebytinybloodclots,specificallyrenalfailureinHUS. TheguidelinesspecifyinthecaseofHIV-relatedconditionsandsepsis,ifthereasonforadmissionisthisinfection-associatedHUS,itissequencedastheprincipaldiagnosis.ForHIV-relateddisease,thismakesmoresense.ThepatientisbeingadmittedbecausetheyhaveHUS,butthereisabackdropofHIV. Thisisgoingtobetrickerwithsepsis.Theprecisewordingis:Ifthereasonforadmissionishemolytic-uremicsyndromethatisassociatedwithsepsis,assigncodeD59.31,Infection-associatedhemolytic-uremicsyndrome,astheprincipaldiagnosis.Codesfortheunderlyingsystemicinfectionandanyotherconditions(suchasseveresepsis)shouldbeassignedassecondarydiagnoses.TheverbiageseemstosuggestthatHUSshouldbesequencedfirst,butIbelievethatitissayingiftheHUSisthereasonforadmission,thenitwouldbesequencedfirst.NotIFthepatienthasHUSinthesettingofsepsis,thenyoumustsequenceitfirst.Itmayverywellbethatthepatientisbeingadmittedforsepsis,andtheyjusthappentohaveHUSasoneoftheiracutesepsis-relatedorgandysfunctions.Thensepsiswouldstillbetheprincipaldiagnosis.IsubmittedarequestforclarificationfromtheCentersforDiseaseControlandPrevention(CDC).I’llletyouknowwhattheyrespond. IntheNeoplasmchapter,theguidelinesclarifythattheprimarymalignancyissequencedasprincipalorfirst-listeddiagnosisifitis“chieflyresponsibleforoccasioningthepatientadmission/encounterandtreatmentisdirectedattheprimarysite.”Conversely,iftreatmentforamalignancysuchaschemotherapy,immunotherapy,orradiationtherapyisthereasonfortheadmission,theZ51.-codewouldbeprincipal/first-listedandthemalignancywouldbeasecondarydiagnosis.Ithasalwaysbeenthatway,butthenewwordingmakesitcrystal-clearnow. InI.C.2.t.,theguidelinesareclarifyingaconceptthatclinicallymakessense.Normally,amalignancythatspreadstoasecondarysiteisfoundinC76-C80,Malignantneoplasmsofill-defined,othersecondaryandunspecifiedsites,subcategorizedbysite,suchaslungorbone.Ifitiscarcinoid,thereisaseparatesubcategoryofsecondaryneuroendocrinetumors.However,ifalymphoidcancer(e.g.,lymphoma)spreadstoasolidorgan,thepropercodetoselecthasthefinalcharacterof9whichindicatesextranodalandsolidorgansites. Allthediabetessections(generalandgestational)hadarevisionclarifyingthatZ79.84,Longtermuseoforalhypoglycemicdrugsisforuseoforalhypoglycemicdrugs,notjustoralmedicationsaspreviouslyindicated.TheguidelinesareintroducingthenewcodeofZ79.85,Longterm(current)useofinjectablenon-insulinantidiabeticdrugstoreplacethegenericotherlongtermdrugtherapyinappropriateinstances. Dementiaisundergoingasignificantexpansionindicatingseverity.GuidelineI.C.5.d.revealsthatifapatientisadmittedatoneseverityandprogresses,onlythehigherlevelisreported. I.C.15.a.7)isanewparagraphstatingthat“InICD-10-CM,”completedweeksofgestationreferstofullweeks.Ihavenoideawhythisadditionwasnecessary.Inmedicineingeneral,weeksofgestationalwaysreferstocompletedweeks.That’swhyyousee“XweeksandYdays”or“XY/7weeks”documented–XweekscompletedandYdaysoutofthenextsevendayswhichwouldindicateanothercompletedweek. P.68givesusinsightintohowtoapproachcomplicationsafteranelectiveabortion(conditionswhicharenotgoingtobelegislatedaway–infact,theywilllikelyincrease).TheygivetheexampleoftheuseofO04.6,Delayedorexcessivehemorrhagefollowing(induced)terminationofpregnancyasopposedtoO72.1,Otherimmediatepostpartumhemorrhage.Postabortionisnotconsideredpostpartum.Similarly,ifthereisacomplication,youwouldn’tuseZ33.2,Encounterforelectiveterminationofpregnancy.Youeitherhaveanuncomplicatedencounteroritiscomplicated;theyaremutuallyexclusiveandhavingaresultantcomplication,bydefinition,indicatesthatyouhadthatprocedure. I.C.19.e.5)(c)spellsoutthefactthatyoudon’tneedtheretobeachangeinthepatient’sconditiontoassignorcaptureanunderdosingcode.Ifthepatienttooklessthanprescribed,evenifnoadverseeffectswereexperienced,underdosingisstillpresentandclinicallysignificant.Ifthereisaworseningorexacerbationofthecondition,thatwouldbeanothercode. I.C.21.c.10)bringsupanothernewcode,Z71.87,Encounterforpediatric-to-adulttransitioncounseling.ThiscanbeusedasasolocodeorcanbeprovidedinadditiontootherconditionssuchaschronicconditionsoranotherZencountercode. Finally,forSocialDeterminantsofHealth(SDoH),theguidanceisthatthesecodesareusedonlywhenthereareproblemsarisingfromtheSDoHorifitposesarisk.Theexampletheyofferisuseful–noteveryindividuallivingaloneshouldbeassignedZ60.2,Problemsrelatedtolivingalone.AnotherexamplewouldbeZ56.1,Changeofjob.Thismightbeaproblemcausinganxietyordepressionwarrantingrecordingandcoding,oritmightbeawelcomesituationandnotbeconsideredanissue.ForSDoHtoimpactmedicaldecisionmaking,the“diagnosisortreatment[needstobe]significantlylimitedbysocialdeterminantsofhealth.” AsIdoeveryyear,IrecommendyoureadtheupdatedICD-10-CMGuidelinesyourself.Itlookslikethereweren’tchangestothePCSguidelines. ProgrammingNote:ListentoDr.RemereveryTuesdaywhensheco-hostsTalkTenTuesdayswithChuckBuck,10Eastern. 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