The ever-evolving healthcare world has been catalyzed by post pandemic times that followed is in turn by changes released by the governing bodies of medical information for better patient care.
The frequency of changes in coding and content updates has increased after the transition from a fee-for-service to a value-based care healthcare model. As the new compensation model is dependent on the class of care delivered, it demands a more comprehensive documentation procedure with a higher focus on maintaining code clarity that accurately conveys the severity of the patient and the service provided.
The governing bodies for medical coding has released the fresh set of changes to be followed for ICD-10 code system for 2023. There are 1176 new billable healthcare codes in the ICD-10-CM code system for 2023 with 28 revised codes, 36 codes converted as parent codes, 83 new codes included in the chapter of Mental, Behavioral, and Neuro-developmental Disorders that contains 69 codes introduced for dementia ( both without and with psychological symptoms).
The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). Let us look into the latest set of ICD-10 updates and changes:
General Coding Guidelines:
- Immunization Status
Documentation by clinicians other than patient’s provider
Code assignment is based on the documentation by the patient’s provider but there are few exceptions when code assignment may be based on medical record documentation from clinicians who are not the patient’s provider.
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
- Under immunization status
Z28.– Can be reported, if clinician documents the immunization status.
- Complication of Care
Documentation of Complication of Care
It is important to note that not all conditions that occur during or following medical care or surgery care are classified as complications. The documentation must support that the condition is clinically significant. For example, if a condition alters the course of the surgery as documented in the operative report then it would be appropriate to report a complication code.
Chapter-Specific Coding Guidelines
In addition to general coding guidelines, there are guidelines for specific diagnoses and/or
conditions in the classification. Unless otherwise indicated, these guidelines apply to all health.
- HIV Infections:
If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, an exception to this guideline is if the reason for admission is hemolytic-uremic syndrome associated with HIV disease. Assign code D59.31, Infection-associated hemolytic-uremic syndrome, followed by code B20.
- Sepsis, Severe Sepsis, and Septic Shock Infections resistant to antibiotics:
If the reason for admission is hemolytic-uremic syndrome that is associated with sepsis, assign code D59.31, Infection-associated hemolytic-uremic syndrome, as the principal diagnosis. Codes for
the underlying systemic infection and any other conditions.
When a malignant neoplasm of lymphoid tissue metastasizes beyond the lymph nodes, a code from categories C81-C85 with a final character “9” should be assigned identifying “extra nodal and solid organ sites” rather than a code for the secondary neoplasm of the affected solid organ.
- Diseases of the blood and blood-forming:
Below are newly updated codes classifications,
- Syndrome Hemolytic Uremic D59.3:
- 30 Hemolytic-uremic syndrome, unspecified
- 31 Infection-associated hemolytic-uremic syndrome
- 32 Hereditary hemolytic-uremic syndrome
- 39 Other hemolytic-uremic syndrome
- Von Willebrand disease D68.0:
- 00, unspecified
- 01 type 1
- 020 type 2A
- 021 type 2B
- 022 type 2M
- 023 type 2N
- 029 type 2, unspecified
- 03 type 3
- 04 Acquired
- 09 Other
- Thrombocytopenia, thrombocytopenic D69.6 heparin induced (HIT) D75.82
- 821 Non-immune heparin-induced thrombocytopenia
- 822 Immune-mediated heparin-induced thrombocytopenia
- 828 Other heparin-induced thrombocytopenia syndrome
- 829 Heparin-induced thrombocytopenia, unspecified
- 84 Other platelet-activating anti-PF4 disorders
- 82 Activated Phosphoinositide 3-kinase Delta Syndrome [APDS]
- Use additional code for adverse effect, if applicable, to identify drug
The ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the etiology and severity (unspecified, mild, moderate or severe). Selection of the appropriate severity level requires the provider’s clinical judgment and codes should be assigned only based on provider.
documentation unless otherwise instructed. If the documentation does not provide information about the severity of the dementia, assign the appropriate code for unspecified severity.
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.
Dementia with behavioral disturbances from Mental, Behavioral, and Neuro-developmental Disorders
- A1 – Vascular dementia, mild
- B1 – Vascular dementia, moderate
- C1 – Vascular dementia, severe
- A1 – Dementia in other diseases classified elsewhere, mild
- B1 – Dementia in other diseases classified elsewhere, moderate
- C1 – Dementia in other diseases classified elsewhere, severe
- A1 – Unspecified dementia, mild
- B1 – Unspecified dementia, moderate
- C1 – Unspecified dementia, severe
- Completed weeks of gestation
In ICD-10-CM, “completed” 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 completed weeks.
- Endometriosis: (a non-exhaustive code list)
- N80.0-N80.02 uterus
- N80.03 Adenomyosis of the uterus
- N80.101-N80.129 Ovaries
- N80.201-N80.229 fallopian tubes
- N80.30 pelvic peritoneum
- N80.311-N80.329 cul-de-sac
- N80.331-N80.359 Pelvic sidewall
- N80.361-N80.389 Pelvic brim
- N80.541-N80.549 Appendix
- N80.B1 Pleura
- N80.B2 Lung
- Concussion: (a non-exhaustive code list)
- 0XA – Concussion with LOC status unknown
- 1XA – Traumatic cerebral edema with LOC status unknown
- 2XA – Diffuse traumatic brain injury with LOC status unknown
- 30A – Unspecified focal traumatic brain injury with LOC status unknown
- 31A – Contusion and laceration of right cerebrum with LOC status unknown
- 32A – Contusion and laceration of left cerebrum with LOC status unknown
- 33A – Contusion and laceration of cerebrum, unspecified, with LOC status unknown
- 34A – Traumatic hemorrhage of right cerebrum with LOC status
- 35A – Traumatic hemorrhage of left cerebrum with LOC status unknown
- 36A – Traumatic hemorrhage of cerebrum, unspecified, with LOC status unknown
- 37A – Contusion, laceration, and hemorrhage of cerebellum with LOC status unknown
- 38A – Contusion, laceration, and hemorrhage of brainstem with LOC status unknown
- 4XA – Epidural hemorrhage with LOC status unknown
- 5XA – Traumatic subdural hemorrhage with LOC status unknown
- 6XA – Traumatic subarachnoid hemorrhage with LOC status unknown
- 81A – Injury of right internal carotid artery, intracranial portion, NEC with LOC status unknown
- 82A – Injury of left internal carotid artery, intracranial portion, NEC with LOC status unknown
- 89A – Other specified intracranial injury with LOC status unknown
- Social Determinants of Health:
Assign as many SDOH codes as are necessary to describe all the problems or risk factors. These codes should be assigned only when the documentation specifies that the patient has an associated problem or risk factor.
- Factors influencing health status and contact with health services:
- Z59.82 Transportation insecurity
- Z59.86 Financial insecurity
- Z59.87 Material hardship
- Z71.87 Encounter for pediatric-to-adult transition counseling
- Z71.88 Encounter for counseling for socioeconomic factors
- Z72.823 Risk of suffocation (smothering) under another while sleeping.
These are the highlights of some of the changes by ICD and the full information can be accessed from the given sources.