Changes coming with 2019 Official Guidelines for Coding and Reporting of ICD-10-CM
The 2019 Official
Guidelines for Coding and Reporting of ICD-10-CM have been released, and they
certainly encompass some notable changes, as always.
Changes occur in the
“Conventions,” the “General Guidelines,” and several chapter-specific
guidelines as well. Narrative changes appear in bold text below;
items underlined have been moved within the guidelines since the FY-2018
version; and italics are used to indicate revisions to heading
changes. The effective date for these changes is Oct. 1, 2018.
Within the coding “Conventions,”
convention No. 15, “with,” there is added wording in bold: 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.
For General Guideline No.
14, the title is revised and has new instructions, plus the addition of
guidance regarding “social determinates.” Health information management (HIM)
coding professionals should read over this guideline change carefully.
For General Guideline No.
14, Documentation by Clinicians Other than the Patient's Provider, code
assignment is based on the documentation by the 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 National
Institutes of Health NIH stroke scale (NIHSS). Code assignment may be based on
medical record documentation from clinicians who are not the patient’s provider
(i.e., the 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).
For social determinants
of health (SDoH), 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.
In the “General Guidelines” section, there is a
new General Guideline, No. 19: Coding for Healthcare Encounters in
Hurricane Aftermath. To wit:
1.
a. Use of External Cause of Morbidity Codes: An
external cause of morbidity code should be assigned to identify the cause of
the injury (or injuries) incurred as a result of the hurricane. The use of
external cause-of-morbidity codes is supplemental to the application of
ICD-10-CM codes. External cause-of-morbidity codes are never to be recorded as
a principal diagnosis (first-listed in non-inpatient settings). The appropriate
injury code should be sequenced before any external cause codes. The external
cause-of-morbidity codes capture how the injury or health condition happened
(cause), the intent (unintentional or accidental; or intentional, such as
suicide or assault), the place where the event occurred, the activity of the
patient at the time of the event, and the person’s status (e.g., civilian,
military). They should not be assigned for encounters to treat hurricane
victims’ medical conditions when no injury, adverse effect, or poisoning is
involved. External cause-of-morbidity codes should be assigned for each
encounter for care and treatment of injury. External cause-of-morbidity codes
may be assigned in all healthcare settings. For the purpose of capturing
complete and accurate ICD-10-CM data in the aftermath of a hurricane, a
healthcare setting should be considered as any location where medical care is
provided by licensed healthcare professionals.
37. b.
Sequencing of External Causes of Morbidity Codes: Codes for cataclysmic events,
such as a hurricane, take priority over all other external cause codes except
child and adult abuse and terrorism, and should be sequenced before other
external cause-of-injury codes. Assign as many external cause-of-morbidity
codes as necessary to fully explain each cause. For example, if an injury
occurs as a result of a building collapse during a hurricane, external cause
codes for both the hurricane and the building collapse should be assigned, with
the external causes code for hurricane being sequenced as the first external
cause code. For injuries incurred as a direct result of the hurricane, assign
the appropriate code(s) for the injuries, followed by the code X37.0-,
Hurricane (with the appropriate seventh character), and any other applicable
external cause-of-injury codes. Code X37.0- also should be assigned when an
injury is incurred as a result of flooding caused by a levee breaking related
to the hurricane. Code X38.-, Flood (with the appropriate seventh character),
should be assigned when an injury is from flooding resulting directly from the
storm. Code X36.0.-, Collapse of dam or manmade structure, should not be
assigned when the cause of the collapse is due to the hurricane. Use of code
X36.0- is limited to collapses of manmade structures due to earth surface
movements, not due to storm surges directly from a hurricane.
37. c.
Other External Causes of Morbidity Code Issues: For injuries that are not a
direct result of the hurricane, such as an evacuee who has incurred an injury as
a result of a motor vehicle accident, assign the appropriate external
cause-of-morbidity code(s) to describe the cause of the injury, but do not
assign code X37.0-, Hurricane. If it is not clear whether the injury was a
direct result of the hurricane, assume this is the case and assign code X37.0-,
Hurricane, as well as any other applicable external cause-of-morbidity codes.
In addition to code X37.0-, Hurricane, other possible applicable external cause
of morbidity codes include: W54.0-, Bitten by dog; X30-, Exposure to excessive
natural heat; X31-, Exposure to excessive natural cold; or X38-, Flood.
59. d. Use
of Z Codes: Z codes (other reasons for healthcare encounters) may be assigned
as appropriate to further explain the reasons for presenting for healthcare
services, including transfers between healthcare facilities. The ICD-10-CM
Official Guidelines for Coding and Reporting identify which codes may be
assigned as principal or first-listed diagnosis only, secondary diagnosis only,
or principal/first-listed or secondary (depending on the circumstances).
Possible applicable Z codes include: Z59.0, Homelessness; Z59.1, Inadequate
housing; Z59.5, Extreme poverty; Z75.1, Person awaiting admission to adequate
facility elsewhere; Z75.3, Unavailability and inaccessibility of healthcare
facilities; Z75.4, Unavailability and inaccessibility of other helping
agencies; Z76.2, Encounter for health supervision and care of other healthy
infant and child; or Z99.12, Encounter for respirator (ventilator) dependence
during power failure.
The external cause-of-morbidity codes and the Z
codes listed above are not an all-inclusive list. Other codes may be applicable
to the encounter based upon the documentation. Assign as many codes as
necessary to fully explain each healthcare encounter. Since patient history
information may be very limited, use any available documentation to assign the
appropriate external cause-of-morbidity and Z codes.
Within the “Chapter-Specific Guidelines,” the
first change we see is in Chapter 1, Certain Infectious and Parasitic Diseases,
for sepsis, under the heading of Sepsis due to a post-procedural infection.
For infections following a procedure, a code from
T81.40 to T81.43, Infection following a procedure, or a code from O86.00 to
O86.03, Infection of obstetric surgical wound, that identifies the site of the
infection should be coded first, if known. Assign an additional code for sepsis
following a procedure (T81.44) or sepsis following an obstetrical procedure
(O86.04). Use an additional code to identify the infectious agent. If the
patient has severe sepsis, the appropriate code from subcategory R65.2 should
also be assigned with the additional code(s) for any acute organ dysfunction.
For infections following infusion, transfusion,
therapeutic injection, or immunization, a code from subcategory T80.2,
Infections following infusion, transfusion, and therapeutic injection, or code
T88.0-, Infection following immunization, should be coded first, followed by
the code for the specific infection. If the patient has severe sepsis, the
appropriate code from subcategory R65.2 should also be assigned, with the
additional codes(s) for any acute organ dysfunction.
If a post-procedural infection has resulted in
post-procedural septic shock, assign the codes indicated above for sepsis due
to a post-procedural infection, followed by code T81.12-, Post-procedural
septic shock. Do not assign code R65.21, Severe sepsis with septic shock.
Additional code(s) should be assigned for any acute organ dysfunction.
Within Chapter 1, there is also a small
change/revision with “Zika virus infection.”
In Chapter 2, Neoplasms, the following small
change was made under the sections Primary malignancy previously excised and
Current malignancy versus personal history of malignancy:
When a primary malignancy has been previously
excised or eradicated from its site, there is no further treatment (of the
malignancy) 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.
When a primary malignancy has been excised but
further treatment, such as an additional surgery for the malignancy, radiation
therapy, or chemotherapy is directed to that site, the primary malignancy code
should be used until treatment is completed.
Subcategories Z85.0-Z85.7 should only be assigned
for the former site of a primary malignancy, not the site of a secondary
malignancy. Codes from subcategory Z85.8- may be assigned for the former
site(s) of either a primary or secondary malignancy included in this
subcategory.
For Chapter 5, Mental, Behavioral, and
Neurodevelopmental Disorders, the following notable changes and the addition of
“Factitious Disorder” guideline have been made:
3) Psychoactive Substance Use, Unspecified: As
with all other unspecified diagnoses, the codes forunspecified psychoactive
substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-,
F18.9-, F19.9-) should only be assigned based on provider documentation and
when they meet the definition of a reportable diagnosis (see Section III,
Reporting Additional Diagnoses).
1.
c. Factitious Disorder
Factitious disorder imposed on self, or
Munchausen’s syndrome, is a disorder in which a person falsely reports or
causes his or her own physical or psychological signs or symptoms. For patients
with documented factitious disorder on self or Munchausen’s syndrome, assign
the appropriate code from subcategory F68.1-, Factitious disorder imposed on
self.
Munchausen’s syndrome by proxy (MSBP) is a
disorder in which a caregiver (perpetrator) falsely reports or causes an
illness or injury in another person (victim) under his or her care, such as a
child, an elderly adult, or a person who has a disability. The condition is
also referred to as “factitious disorder imposed on another” or “factitious
disorder by proxy.” The perpetrator, not the victim, receives this diagnosis.
Assign code F68.A, Factitious disorder imposed on another, to the perpetrator’s
record. For the victim of a patient suffering from MSBP, assign the appropriate
code from categories T74, Adult and child abuse, neglect and other
maltreatment, confirmed, or T76, Adult and child abuse, neglect and other
maltreatment, suspected.
See Section I.C.19.f. Adult and child abuse,
neglect and other maltreatment
There are other changes/revisions in the
following chapters, and these should be read through thoroughly:
- Chapter
9, Diseases of the Circulatory System (Hypertension with Heart Disease;
Hypertensive Chronic Kidney Disease; and Subsequent Acute Myocardial
Infarction)
- Chapter
15, Pregnancy, Childbirth and the Puerperium (Drug use during pregnancy,
childbirth and the puerperium)
- Chapter
18, Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not
Elsewhere Classified (Glasgow coma scale)
- Chapter
19, Injury, Poisoning, and Certain Other Consequences of External Causes
(burns of the same anatomic site; underdosing; adult and child abuse,
neglect and other maltreatment)
- Chapter
21, Factors Influencing Health Status and Contact with Health Service
(Body Mass Index; Prophylactic Organ Removal)
- Be
sure to learn more about these and other changes, and be ready for Oct. 1.
All hospital inpatient and outpatient (including physician office) coding
professionals are to apply the new guidelines for discharges occurring
from Oct. 1, 2018 through Sept. 30, 2019. It’s also important for clinical
documentation improvement (CDI) professionals to review the changes.
