CM Guideline Changes

ICD-10-CM Guideline I.A.15.

    • “With” The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index (either under a main term or sub-term), or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”).
    • For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related.
    • The word “with” in the Alphabetic Index is sequenced immediately following the main term or sub-term, not in alphabetical order.

ICD-10-CM Guideline I.C.1.d.4

Sepsis and or Severe Sepsis With a Localized Infection

 

    • If the reason for admission is sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis, a code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis. If the patient has severe sepsis, a code from subcategory R65.2 should also be assigned as a secondary diagnosis. If the patient is admitted with a localized infection, such as pneumonia, and sepsis/severe sepsis doesn’t develop until after admission, the localized infection should be assigned first, followed by the appropriate sepsis/severe sepsis codes

Note: The word “And” is taken out; replaced by “or”, to avoid the confusion that both do not need to be present. Note how this further does not support sepsis 3 criteria.

ICD-10-CM Guideline I.C.1.f.1)

Code Only Confirmed Cases

    • Code only a confirmed diagnosis of Zika virus (A92.5, Zika virus disease) as documented by the provider. This is an exception to the hospital inpatient guideline Section II, H. In this context, “confirmation” does not require documentation of the type of test performed; the physician’s/provider’s diagnostic statement that the condition is confirmed is sufficient. This code should be assigned regardless of the stated mode of transmission.

 

ICD-10-CM Guideline I.C.2.d.

Primary Malignancy Previously Excised

    • When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed diagnosis with the Z85 code used as a secondary code.

ICD-10-CM Guideline I.C.9.e.5)

Other Types of Myocardial Infarction

 

    • The ICD-10-CM provides codes for different types of myocardial infarction. Type 1 myocardial infarctions are assigned to codes I21.0-I21.4 and I21.9.
    • Type 2 myocardial infarction (myocardial infarction due to demand ischemia or secondary to ischemic imbalance) is assigned to code I21.A1, Myocardial infarction type 2 with the underlying cause coded first. Do not assign code I24.8, other forms of acute ischemic heart disease, for the demand ischemia. If a type 2 AMI is described as NSTEMI or STEMI, only assign code I21.A1. Codes I21.01-I21.4 should only be assigned for type 1 AMIs.

Note: Error fix and more clarity. This small change causes a big impact in the sequencing; you cannot no longer code the type 2 MI first when the underlying cause is documented.

 

ICD-10-CM Guideline I.C.12.a.1)

Pressure Ulcer Stages

    • Codes from in category L89, Pressure ulcer, identify the site and stage of the pressure ulcer as well as the stage of the ulcer.
    • The ICD-10-CM classifies pressure ulcer stages based on severity, which is designated by stages 1-4, deep tissue pressure injury, unspecified stage, and unstageable.
    • Assign as many codes from category L89 as needed to identify all the pressure ulcers the patient has, if applicable.

a.4) Patients Admitted With Pressure Ulcers Documented as Healed

    • No code is assigned if the documentation states that the pressure ulcer is completely healed at the time of admission.

a.5) Patients admitted with Pressure Ulcers Documented as Healing

    • Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record. If the documentation does not provide information about the stage of the healing pressure ulcer, assign the appropriate code for unspecified stage.
    • If the documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider.
    • For ulcers that were present on admission but healed at the time of discharge, assign the code for the site

a.7) Pressure-induced Deep Tissue Damage

    • For pressure-induced deep tissue damage or deep tissue pressure injury, assign only the appropriate code for pressure-induced deep tissue damage (L89.6).

b.1) Patients Admitted With Non-pressure Ulcers Documented as Healed

    • No code is assigned if the documentation states that the non-pressure ulcer is completely healed at the time of admission.

b.2) Patients admitted with Non-pressure Ulcers Documented as Healing

  • Non-pressure ulcers described as healing should be assigned the appropriate non-pressure ulcer code based on the documentation in the medical record. If the documentation does not provide information about the severity of the healing non-pressure ulcer, assign the appropriate code for unspecified severity. (portion of the guideline)

ICD-10-CM Guideline I.C.15.n.1)

Encounter for Full Term Uncomplicated Delivery

  • Code O80 should be assigned when a woman is admitted for a full-term normal delivery and delivers a single, healthy infant without any complications antepartum, during the delivery, or postpartum during the delivery episode. Code O80 is always a principal diagnosis. It is not to be used if any other code from chapter 15 is needed to describe a current complication of the antenatal, delivery, or perinatal postnatal period. Additional codes from other chapters may be used with code O80 if they are not related to or are in any way complicating the pregnancy.
  • The term “perinatal” means anytime related to the natal period, therefore it needed to be changed to postnatal here to clarify.

ICD-10-CM Guideline I.C.15.q.2)

Retained Products of Conception Following an Abortion

    • Subsequent encounters for retained products of conception following a spontaneous abortion or elective termination of pregnancy, without complications are assigned O03.4, Incomplete spontaneous abortion without complication, or code O07.4, Failed attempted termination of pregnancy without complication. This advice is appropriate even when the patient was discharged previously with a discharge diagnosis of complete abortion. If the patient has a specific complication associated with the spontaneous abortion or elective termination of pregnancy in addition to retained products of conception, assign the appropriate complication in category O03 or O07 code (e.g., O03.-, O04.-, O07.-) instead of code O03.4 or O07.4.

ICD-10-CM Guideline I.C.16.b.2)

Z05 On A Other Than the Birth Record

    • A code from category Z05 may also be assigned as a principal or first-listed code for readmissions or encounters when the code from category Z38 code no longer applies. Codes from category Z05 are for use only for healthy newborns and infants for which no condition after study is found to be present.

ICD-10-CM Guideline I.C.17.

  • Codes from Chapter 17 may be used throughout the life of the patient. If a congenital malformation or deformity has been corrected, a personal history code should be used to identify the history of the malformation or deformity. Although present at birth, a malformation/deformation/or chromosomal abnormality may not be identified until later in life. Whenever the condition is diagnosed by the physician provider, it is appropriate to assign a code from codes Q00-Q99. For the birth admission, the appropriate code from category Z38, Liveborn infants, according to place of birth and type of delivery, should be sequenced as the principal diagnosis, followed by any congenital anomaly codes, Q00-Q99.

ICD-10-CM Guideline I.C.19…

b.3) Iatrogenic Injuries

  • Injury codes from Chapter 19 should not be assigned for injuries that occur during, or as a result of, a medical intervention. Assign the appropriate complication code(s).

 

c.3) Physeal Fractures

    • For physeal fractures, assign only the code identifying the type of physeal fracture. Do not assign a separate code to identify the specific bone that is fractured.

ICD-10-CM Guideline I.19.e.4)

If two or more drugs, medicinal or biological substances

    • If two or more drugs, medicinal or biological substances are reported taken, code each individually unless a combination code is listed in the Table of Drugs and Chemicals.
    • If multiple unspecified drugs, medicinal or biological substances were taken, assign the appropriate code from subcategory T50.91, Poisoning by, adverse effect of and underdosing of multiple unspecified drugs, medicaments and biological substances.

ICD-10-CM Guideline I.C.19.g.5)

    • Complications of care codes within the body system chapters
    • Intraoperative and postprocedural complication codes are found within the body system chapters with codes specific to the organs and structures of that body system. These codes should be sequenced first, followed by a code(s) for the specific complication, if applicable.
    • Complication codes from the body system chapters should be assigned for intraoperative and postprocedural complications (e.g., the appropriate complication code from chapter 9 would be assigned for a vascular intraoperative or postprocedural complication) unless the complication is specifically indexed to a T code in chapter 19. This is only the applicable portion of the guideline that has a change:

ICD-10-CM Guideline I.C.21.c.3)

  • Z68 Body Mass Index (BMI)
        • BMI codes should only be assigned when the there is an associated, reportable diagnosis (such as overweight or obesity) meets the definition of a reportable diagnosis (See section III, Reporting Additional Diagnoses). Do not assign BMI codes during pregnancy.
        • Note further clarifying that you only assign the code if the associated diagnosis is reportable, but does not require it to meet the definition of reportable secondary diagnoses.

ICD-10-CM Guideline I.21.c.10)

This is only the applicable portion of the guideline that has a change:

    • Z71 Persons encountering health services for other counseling and medical advice, not elsewhere classified

Note: Code Z71.84, Encounter for health counseling related to travel, is to be used for health risk and safety counseling for future travel purposes.

ICD-10-CM Guideline II. H.

Uncertain Diagnosis

    • If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

ICD-10-CM Guideline III. C.

Uncertain Diagnosis

    • If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

ICD-10-CM Guideline IV.G.

ICD-10-CM Code For the Diagnosis, Condition, Problem, or Other Reason for Encounter/Visit

    • List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases, the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician provider.

ICD-10-CM Guideline IV.H.

Uncertain Diagnosis

    • Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” compatible with,” “consistent with,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.

Note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.