New guidelines remove ambiguity for some diagnosis coding in 2023.
The ICD-10-CM Official Guidelines for Coding and Reporting is updated every year, but if you’re not in the habit of reviewing the guidelines at least annually, chances are your diagnosis coding is noncompliant and your claim denial rate is high.
In the general session Diagnosis Coding Insights from the Experts Panel, a medical auditor emphasized the importance of these guidelines. If you don’t read those, you’re probably missing some of the story. The patient’s story, that is, as told by the healthcare professional.
Other panelists proceeded to review changes to the diagnosis coding guidelines that went into effect Oct. 1. Here’s an abridged version of what came out of that session.
Start at the Beginning
Diagnosis coding is only as accurate as the documentation on which it’s based. If there is missing or conflicting information, a coder’s only recourse is to query the provider. Under Section 1.A.19 Conventions for ICD-10-CM, the guideline is modified to support this. If there is conflicting medical record documentation, query the provider.
Section 1.B.16 Documentation of Complications of Care reiterates this point. Query the provider for clarification if the documentation is not clear as to the relationship between the condition and the care or procedure.
I love when we see ‘query the provider clinical documentation specialist said, because it gives a nod to the way the industry is going. … Being able to truly partner with our providers in an effective way and give them actionable information at the point of care, that’s exciting.
Section 1.B.16 is revised further to clarify that the documentation must support that the condition is clinically significant. It is not necessary for the provider to explicitly document the term ‘complication.’ For example, if the condition alters the course of the surgery as documented in the operative report, then it would be appropriate to report a complication code.
Presently working in compliance, an Approved Instructor, drew from her own experience to further explain this concept. “We see on the facility side a lot where providers will put down ‘malnutrition’ for patients, but they don’t actually treat it, they don’t do anything to show that it impacts the care or increases the length of stay. … it really has to be documented as impacting the care to be counted as a complication,” she said.
Another guideline change is in Section 1.B.14 and pertains to documentation by clinicians other than the patient’s provider. “Underimmunization status” is added to the list of diagnoses that may be documented by other clinicians involved in the care of the patient and reported as a secondary diagnosis.
This tells us that it’s not only on the primary care doctor anymore; now we have the support staff who can document these conditions.
Go From Chapter to Chapter
The panelists then went on to review changes to the chapter-specific guidelines. Surprisingly, there weren’t too many additions.
Chapter 1: Certain infectious and parasitic diseases (A00-B99)
When coding human immunodeficiency virus (HIV) infections, there is a new exception to the guideline that says the principal diagnosis should be B20 Human immunodeficiency virus [HIV] disease if a patient is admitted for an HIV-related condition. For fiscal year 2023, if the reason for admission is hemolytic-uremic syndrome associated with HIV disease, you will instead assign new code D59.31 Infection-associated hemolytic-uremic syndrome followed by B20.
Further down in this chapter, this same concept is applied to hemolytic-uremic syndrome with sepsis. “If the reason for admission is hemolytic-uremic syndrome that is associated with sepsis … Codes for the underlying systemic infection and any other conditions (such as severe sepsis) should be assigned as secondary diagnoses,” it reads.
In this case, it’s important to know the true reason for the admission. In many cases, it may still be the sepsis.
Chapter 2: Neoplasms (C00-D49)
You will find some added verbiage under 1.C.2.a Admission/Encounter for treatment of primary site and 1.C.2.t Secondary malignant neoplasm of lymphoid tissue. The update didn’t change the meaning of this guideline. Documentation must show what is the primary malignancy, what is a secondary malignancy, and what is history.
Chapter 5: Mental, behavioral, and neurodevelopmental disorders (F01-F99)
The ICD-10-CM code set update for 2023 includes many new codes for reporting dementia under 1.C.5.d.
One thing that is very important, If a patient is admitted to an inpatient acute care hospital or other inpatient facility setting with dementia at one severity level and it progresses to a higher severity level, assign one code for the highest severity level reported during the stay.
Chapter 15: Pregnancy, childbirth, and the puerperium (O00-O9A)
A new guideline at 1.C.15.a.7 clarifies how to code weeks of gestation. It states:
In ICD-10-CM, “complete” weeks of gestation refers to full weeks. For example, if the provider documents gestation at 39 weeks and 6 days, the code for 39 weeks of gestation should be assigned, as the patient has not yet reached 40 complete weeks.
Another new guideline added in this chapter at 1.C.15.q.4 clarifies proper coding of hemorrhage following elective abortion.
Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)
At Section 1.C.19.5.c. Underdosing, the following is added:
Documentation of a change in the patient’s condition is not required in order to assign an underdosing code.
Documentation that the patient is taking less of a medication than is prescribed or discontinued the prescribed medication is sufficient for code assignment.
When we’re talking about social determinants of health and about providing better outcomes, knowing which of our patients are not taking their prescriptions as prescribed is such an important piece of the story. The reason why they aren’t taking them is equally important.
Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
A guideline at 1.C.21.c.10 is added for new social determinants of health (SDOH) code Z71.87 Encounter for pediatric-to-adult transition counseling. It explains that if both counseling and medical treatment are provided during the same encounter, sequencing depends on the circumstances of the encounter.
For More Information: 86218 icd 10 cm guideline revisions revealed