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)
Laterality
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.
care settings.
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.
Neoplasms:
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
Dementia:
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.
Sources:
These are the highlights of some of the changes by ICD and the full information can be accessed from
the given sources.