Date Posted: Saturday,
November 20, 2021
Well, we are nearing the end of the year, so we all know what that means: coding updates! The ICD-10-CM and ICD-10-PCS updates went into effect October 1st and CPT and HCPCS II codes will go into effect on January 1st. This article will highlight some of the ICD-10-CM guideline changes for 2022.
As far as codes are concerned, there are fewer changes than there were last year: 159 new codes were added, 25 codes were deleted, and 27 codes were revised. There were also changes to the ICD-10-CM Official Guidelines for Coding and Reporting. It is important that health information (HI) professionals familiarize themselves with both the codes and the guidelines to ensure proper reporting of diagnosis codes. The General Guideline changes this year indicate the significance of medical record documentation. They also support the importance of HI professionals (referred to as "coder" in the guidelines).
General ICD-10-CM Official Guideline Changes
The first addition found in the general guidelines is in Section I.B.2, Level of Detail in Coding. I like these types of changes, as they solidify the stress on how important documentation is in the medical record. It now states that "Diagnosis codes are to be used and reported at their highest number of characters available and to the highest level of specificity documented in the medical record" (emphasis added).
The next change is in Section I.B.13, Laterality. It emphasizes that unspecified laterality code usage should be rare, and if used, signifies insufficient documentation (Hint: Red Flag!). But it also puts responsibility on the HI professional to query in such cases.
The coding guideline states:
"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."
In some cases, code assignment may be based on a clinician that is not the patient's provider (BMI, Glasgow Coma Scale, etc.). Section I.B.14 defines these clinicians:
"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:
- Body Mass Index (BMI)
- Depth of non-pressure chronic ulcers
- Pressure ulcer stage
- Coma scale
- NIH stroke scale (NIHSS)
- Social determinants of health (SDOH)
- Blood alcohol level."
The relationship between the physician/other provider and HI professional is emphasized in the addition to the guideline on the use of signs/symptoms and unspecified codes (I.B.18):
"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 Guideline Changes
Chapter 1: Certain Infectious and Parasitic Diseases
There was an addition to the guidelines for coding HIV when a patient has a history of HIV that is managed by medication (I.C.1.a.2.i). There has been a long-standing coding rule that once a patient has been diagnosed as having HIV disease or AIDS that code B20 must be reported on every subsequent encounter (you can't go back to coding Z21, Asymptomatic HIV status). So, what happens when a patient with HIV disease is managed on medications and now has an undetectable level? The guidelines state:
"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."
Of course, there were some additions for COVID-19, also. There was a change to the guideline on follow-up visits after a COVID-19 infection has resolved (I.C.1.g.1.j). It now states:
"For individuals who previously had COVID-19, without residual symptom(s) or condition(s), and are being seen for follow-up evaluation, and COVID-19 test results are negative, assign codes Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm, and Z86.16, Personal history of COVID-19. For follow-up visits for individuals with symptom(s) or condition(s) related to a previous COVID-19 infection, see guideline I.C.1.g.1.m."
This leads to the new guideline (I.C.1.g.1.m) on coding of sequelae and situations where a patient has had COVID-19 previously and now is diagnosed with a new COVID-19 infection. It also introduces the new ICD-10-CM code for COVID sequela, or late effects:
"For sequela of COVID-19, or associated symptoms or conditions that develop following a previous COVID-19 infection, 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, Post COVID-19 condition, unspecified. Code U09.9 should not be assigned for manifestations of an active (current) COVID-19 infection. If a patient has a condition(s) associated with a previous COVID-19 infection and develops a new active (current) COVID-19 infection, code U09.9 may be assigned in conjunction with code U07.1, COVID-19, to identify that the patient also has a condition(s) associated with a previous COVID-19 infection. Code(s) for the specific condition(s) associated with the previous COVID-19 infection and code(s) for manifestation(s) of the new active (current) COVID-19 infection should also be assigned."
Take an example of a patient who had COVID-19 and has a late effect of anosmia that has persisted. He presents with new onset of fever and acute cough, and, after X-rays and testing, is diagnosed with pneumonia due to COVID-19.
In this scenario, the diagnosis codes reported would be:
- U07.1, COVID-19
- J12.82 Pneumonia due to coronavirus disease
- R43.0, Anosmia
- U09.9, Post COVID-19 condition
Chapter 2: Neoplasms
There was one additional guideline added for chapter 2 for breast implant associated anaplastic large cell lymphoma, or BIA-ALCL (I.C.2.s): "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." An important piece to pick up here is that no chapter 19 code for complication needs to be additionally reported.
Chapter 4: Endocrine, Nutritional, and Metabolic Diseases
The only change in the guidelines in chapter 4 relate to diabetes and the use of insulin and oral medication (I.C.4.a.3). Previously, if a diabetic patient was treated with both oral medications and insulin, only the code for long-term current use of insulin was assigned. The new guideline adjusts that: "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" (emphasis added). The same guideline change is listed for secondary diabetes, also.
Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders
There were two new guidelines added to chapter 5 associated with psychoactive substance abuse and blood alcohol levels. The first one (I.C.5.b.4) states that medical conditions due to substance use/abuse/dependence are not substance-induced disorders and should not be reported with a code from subcategory F10.2:
"Medical conditions due to substance use, abuse, and dependence are not classified as substance-induced disorders. Assign the diagnosis code for the medical condition as directed by the Alphabetical Index along with the appropriate psychoactive substance use, abuse or dependence code. For example, for alcoholic pancreatitis due to alcohol dependence, assign the appropriate code from subcategory K85.2, Alcohol induced acute pancreatitis, and the appropriate code from subcategory F10.2, such as code F10.20, Alcohol dependence, uncomplicated. It would not be appropriate to assign code F10.288, Alcohol dependence with other alcohol-induced disorder."
The second one allows the blood alcohol level to be assigned when documented by other than the patient's provider:
"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."
Chapter 12: Diseases of the Skin and Subcutaneous Tissue
Unstageable pressure ulcers had a new directive added under I.C.12.2: "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." So, if a physician documents that a patient has an unstageable pressure ulcer on the right buttock (L89.310), debrides it, then documents it to be a Stage III ulcer, only code the stage III ulcer (L89.313), not both.
Chapter 15: Pregnancy, Childbirth, and the Puerperium
Chapter 15 contains a clarification on what to do when a woman presents for a delivery and there is a complication, but no "in childbirth" option exists: "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."
Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified
Chapter 18 had an addition to the coma scale guidelines. Prior to this update, the Glasgow Coma Scale (GCS) codes were only to be used with traumatic brain injuries (TBI). In the 2022 guidelines, it states that "Code R40.20, Unspecified coma, may be assigned in conjunction with codes for any medical condition" (I.C.18.e). This then caused a change to I.C.18.1, Coma Scale in the code range: "The coma scale codes (R40.21- to R40.24-) can be used in conjunction with traumatic brain injury codes."
There is a 7th character extender on subcategory R40.2- (GCS total score) that indicates when the scale was documented. As an inpatient, the GCS may be repeated multiple times within the first 24 hours. The other addition (I.C.18.1.1) directs which score should be coded: "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."
Chapter 21: Factors Influencing Health Status and Contact with Health Services
The biggest change to chapter 21 is the Social Determinants of Health (SDOH) section. But there were a few others. First, with history of codes, the guideline gives sequencing instructions: "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 slight change to the donor section (I.C.21.9) to state that the category Z52 codes are for individuals donating for others, as well as for self-donations.
The counseling guidelines had an addition for the new code Z71.85, Encounter for immunization safety counseling: "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." So, it is not for normal counseling when a mother, for example, is presenting for her child's regularly scheduled immunizations. This could be used for a discussion with a patient over the safety of the COVID vaccine if they are hesitant to receive it, as an example.
The final new guideline (and the largest in the chapter) is for SDOH. It allows HI professionals to pull data from other documentation (such as social worker's note) if it is in the official medical record:
"Codes describing social determinants of health (SDOH) should be assigned when this information is documented. For social determinants of health, such as information found in categories Z55-Z65, persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient's provider since this information represents social information, rather than medical diagnoses. For example, coding professionals may utilize documentation of social information from social workers, community health workers, case managers, or nurses, if their documentation is included in the official medical record. Patient self-reported documentation may be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the medical record by either a clinician or provider."
Social determinants of health codes are located primarily in these Z code categories:
- Z55 Problems related to education and literacy
- Z56 Problems related to employment and unemployment
- Z57 Occupational exposure to risk factors
- Z58 Problems related to physical environment
- Z59 Problems related to housing and economic circumstances
- Z60 Problems related to social environment
- Z62 Problems related to upbringing
- Z63 Other problems related to primary support group, including family circumstances
- Z64 Problems related to certain psychosocial circumstances
- Z65 Problems related to other psychosocial circumstances
Of course, it is critical to look at the actual new, deleted, and revised codes as that is what will be reported on the claim form and counted for statistical data. But, just as critical are the guidelines. I oftentimes have people tell me that they always look for the new codes, but don't read the guidelines. It's like peanut butter without the jelly; hot chocolate without marshmallows; the Captain without Tennille.
Looking at the codes without understanding how to use them can lead to misreporting and possible denials.
Betty Hovey, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I,
is the Senior Consultant/Owner of Compliant Health Care Solutions, a medical consulting firm that provides compliant solutions to issues for all types of healthcare entities. Chcs.consulting
2022 ICD-10-CM Official Guidelines for Coding and Reporting. 2022 ICD-10-CM Guidelines (cms.gov)