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 exceptionssuch 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.


  1. 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.


  1. 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.


  1. 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 for unspecified 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.

Access the full Official Guidelines for Coding and Reporting online at:



Program Note:

Listen to Gloryanne Bryant report on topic today on Talk Ten Tuesday, 10 a.m. EDT.

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Gloryanne Bryant, RHIA, CDIP, CCS, CCDS

Gloryanne is an HIM coding professional and leader with more than 40 years of experience. She has an RHIA, CDIP, CCS, and a CCDS. For the past six years she has been a regular speaker and contributing author for ICD10monitor and Talk Ten Tuesdays. She has conducted numerous educational programs on ICD-10-CM/PCS and CPT coding and continues to do so. Ms. Bryant continues to advocate for compliant clinical documentation and data quality. She is passionate about helping healthcare have accurate and reliable coded data.

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