Revisions to the ICD-10-CM Guidelines for 2019

The 2019 edition of the ICD-10-CM Official Guidelines for Coding and Reporting were released by the National Center for Health Statistics (NCHS) on July 26, 2018. There are some changes that will affect code assignment for radiology services. This article will highlight only the most important changes relevant to radiology, but the complete guidelines (120 pages) can be downloaded from the NCHS website at: https://www.cdc.gov/nchs/icd/icd10cm.htm

Please see the separate article in this issue for a discussion of the 2019 ICD-10-CM code changes.

“With”

The guideline regarding the term “with” has been revised to clarify that it applies when the term “with” or “in” appears under either a main term or a subterm. The 2019 guideline states:

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 subterm), 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”).

Documentation by Other Clinicians

Section I.B.14 of the Guidelines has been retitled “Documentation by Clinicians Other than the Patient’s Provider.” The guideline has been revised to indicate that code assignment for body mass index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) may be based on documentation from clinicians who are not the patient’s provider (for example, dietician, nurse, or EMT). However, the associated diagnosis must be documented by the patient’s provider.

Also added to this guideline is a statement regarding social determinants of health, such as those found in categories Z55-Z65. Code assignment of social determinants of health may be based on documentation from clinicians who are involved in the patient’s care, but are not the patient’s provider. The 2019 guideline reads:

Code assignment is based on the documentation by patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). There are a few exceptions, such as codes for the Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes, 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), since this information is typically 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, or pressure ulcer) 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.

For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses. The BMI, coma scale, NIHSS codes and categories Z55-Z65 should only be reported as secondary diagnoses.

Hurricane Aftermath

A new section was added for “Coding for Healthcare Encounters in Hurricane Aftermath.” These guidelines discuss the use and sequencing of external cause codes for injuries that are incurred as a result of a hurricane. If it is unclear whether an injury is a result of a hurricane, assume that it is. In the aftermath of a hurricane, a healthcare setting “should be considered as any location where medical care is provided by licensed healthcare professionals.” See Section I.B.19 for more information.

Zika Virus

The guideline on Zika virus infections was revised to reflect the new code Z20.821 [Contact with and (suspected) exposure to Zika virus].

Neoplasms

The guideline for primary malignancy previously excised was revised to clarify that there must be “no evidence of any existing primary malignancy at that site.” The phrase “at that site” was added to distinguish between the previous primary malignancy versus a new one at a different site.

Additionally, there is a new paragraph stating that subcategories Z85.0-Z85.7 should be used only for the former site of the primary malignancy, not the site of a secondary malignancy. However codes from subcategory Z85.8 can be used for the former site of a primary or a secondary malignancy.

Hypertensive Heart Disease

The revised guideline states that hypertension with conditions classified to I50.- or I51.4-I51.7, I51.89, I51.9 are assigned to a code from category I11. This effectively removes code I51.81 (Takotsubo syndrome) from the guideline. A later statement regarding coding these conditions separately when documented that they are unrelated by the physician also removes code I51.81.

Hypertensive Chronic Kidney Disease

The guideline has been update to read that CKD should not be coded as hypertensive if the provider “indicates the CKD is not related to the hypertension” from “has specifically documented a different cause.”

Pulmonary Hypertension

The guideline has been updated to indicate that sequencing is based on the reason for encounter, except for adverse effects of drugs.

Myocardial Infarction

A new paragraph has been added to the guideline for subsequent myocardial infarction (MI). It states:

If a subsequent myocardial infarction of one type occurs within 4 weeks of a myocardial infarction of a different type, assign the appropriate codes from category I21 to identify each type. Do not assign a code from I22. Codes from category I22 should only be assigned if both the initial and subsequent myocardial infarctions are type 1 or unspecified.

Section I.C.9.e.5 was updated to state that a Type 1 MI is assigned to codes I21.0-I21.4 and I21.9.

Coma Scale

A new paragraph has been added to the guideline stating that the codes for individual or total Glasgow coma scale scores should not be used for a patient in a medically induced coma or for a sedated patient.

Underdosing

The guideline for underdosing has been revised to specify that when a patient stops the use of a prescribed medication on his or her own initiative, it is also classified as an underdosing.

- Article by Coding Strategies® Staff