Released earlier than usual, the fiscal year (FY) 2022 ICD-10-CM Official Guidelines for Coding and Reporting became available online Monday, July 12, and include instructions for assigning novel code U09.9 Post COVID-19 condition (found under Section I.C.1.g.1). Familiarize yourself with the following new and revised guidance, effective October 1, to ensure proper diagnosis coding and reporting.
Updates to General Coding Guidelines
Section I.B.13 – Laterality
Under this section, the following paragraph is added:
“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.”
Section I.B.14 – Documentation by Clinicians Other Than the Patient’s Provider
Changes to this section are primarily clarifications surrounding coding based on another clinician’s medical documentation. Guideline updates appear in bold text.
“There are a few exceptions when code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). 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
This information is typically, or may be, 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, pressure ulcer, or a condition classifiable to category F10, Alcohol related disorders) 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 scale, NIHSS, blood alcohol level codes and codes for social determinants of health should only be reported as secondary diagnoses. See Section I.C.21.c.17 for additional information regarding coding social determinants of health.“
Section I.B.18 – Use of Sign/Symptom/Unspecified Codes
New to this section is the following paragraph:
“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.”
Changes to Chapter-Specific Coding Guidance
Chapter-specific updates to the ICD-10-CM guidelines for FY2022 include:
Section I.C.1.a.2.i – History of HIV Managed by Medication
Further instruction is added to this guideline:
“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.”
Section I.C.1.g.1 – COVID-19 Infection (Infection Due to SARS-CoV-2)
You’ll find that COVID-19 guidelines have been slightly modified from their previous versions in these sections:
- Section I.C.1.g.1.e – Sequencing of codes
- Section I.C.1.g.1.g – Signs and symptoms without definitive diagnosis of COVID-19
- Section I.C.1.g.1.j – Follow-up visits after COVID-19 infection has resolved
- Section I.C.1.g.1.l – Multisystem Inflammatory Syndrome
The last update is the addition of Section I.C.1.g.1.m, which clarifies coding for post-COVID-19 conditions.
Section I.C.2.s – Breast Implant Associated Anaplastic Large Cell Lymphoma
This section is new for 2022. Added is guidance that states:
“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.”
Section I.C.4.a – Diabetes Mellitus
Major changes include modifications to the following sections:
- Section I.C.4.a.3 – Diabetes mellitus and the use of insulin, oral hypoglycemics, and injectable non-insulin drugs
- Section I.C.4.a.6.a – Secondary diabetes mellitus and the use of insulin, oral hypoglycemic drugs, or injectable non-insulin drugs
Section I.C.5.b – Mental and Behavioral Disorders Due to Psychoactive Substance Use
Updates to this chapter include slight modification of the verbiage in Section I.C.5.b.3. You’ll also want to review these two new guidelines:
Section I.C.5.b.4 – Medical Conditions Due to Psychoactive Substance Use, Abuse and Dependence
Section I.C.5.b.5 – Blood Alcohol Level
Section I.C.12.a.2 – Unstageable Pressure Ulcers
Here, ICD-10-CM adds some additional context to consider:
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.
Section I.C.15.a – General Rules for Obstetric Cases
Under Section I.C.15.a.3, the following clarification is added (changes appear in bold text):
Whenever delivery occurs during the current admission, and there is an “in childbirth” option for the obstetric complication being coded, the “in childbirth” code should be assigned. 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.
Section I.C.18.e – Coma
Make sure to check out the subtle revisions to this section, such as new and modified verbiage and some reorganization. Key changes (in bold) include:
- New introductory statement that you can report code R40.20 Unspecified coma in conjunction with codes for any medical condition.
- The next sentence was moved up and modified: “Do not report codes for unspecified coma, individual or total Glasgow coma scale scores for a patient with a medically induced coma or a sedated patient.”
- Addition of Section I.C.18.e.1 – Coma Scale and moving the remainder of the original guideline verbiage under this new section. Here, the revised coma scale code parenthetical statement now reads (R40.21- to R40.24-).
- Under Section I.C.18.e.1, addition of the following, “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.”
Section I.C.19.d.6 – Burns and Corrosions Classified According to Extent of Body Surface Involved
In Chapter 19, ICD-10-CM modifies the wording of this guideline slightly (changes appear in bold text):
- Assign codes from category T31, Burns classified according to extent of body surface involved, or T32, Corrosions classified according to extent of body surface involved, for acute burns or corrosions when the site of the burn or corrosion is not specified or when there is a need for additional data. It is advisable to use category T31 as additional coding when needed to provide data for evaluating burn mortality, such as that needed by burn units. It is also advisable to use category T31 as an additional code for reporting purposes when there is mention of a third-degree burn involving 20 percent or more of the body surface. Codes from categories T31 and T32 should not be used for sequelae of burns or corrosions.
Section I.C.21 – Factors Influencing Health Status and Contact With Health Services (Z00-Z99)
There are several updates to the guidelines in this chapter you should note. Key changes include:
- Revised heading for Section I.C.21.b – Z Codes Indicate a Reason for an Encounter or Provide Additional Information about a Patient Encounter (added verbiage in bold)
- Further instruction in Section I.C.21.c.4 – History (of). Before the list of the history Z code categories, is the following addition: “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 new set of instructions to consider in Section I.C.21.c.10 – Counseling. Following the note for Z71, it now states, “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.”
- Addition of Section I.C.21.c.17 – Social Determinants of Health
For more information: https://www.aapc.com/blog/80229-2022-icd-10-cm-guidelines-released/