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The effective date for the FY 2022 Official Guidelines is Oct. 1, 2021

Released earlier in the year than in the past, the Official Guidelines for Coding and Reporting of ICD-10-CM became available online on July 12. You can access the full guideline document at the Centers for Disease Control and Prevention (CDC) website: 2022 ICD-10-CM Guidelines (cdc.gov).

There are several small changes to the Guidelines that are noteworthy. For example, General Coding Guideline No. 13 has this guidance added:

  • When laterality is not documented by the patient’s provider, code assignment for the affected side may be based on medical record documentation from other clinicians. If there is conflicting medical record documentation regarding the affected side, the patient’s attending provider should be queried for clarification. Codes for “unspecified” side should rarely be used, such as when the documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification.

Another revision occurs with General Coding Guideline No. 14 (bolded wording represents the changes):

  • 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 when 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). In this context, “clinicians” other than the patient’s provider refer to healthcare professionals permitted, based on regulatory or accreditation requirements or internal hospital policies, to document in a patient’s official medical record. 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

This information is typically, or may be, 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, pressure ulcer, or a condition classifiable to category F10, Alcohol related disorders) 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. The BMI, coma scale, NIHSS, blood alcohol level codes and codes for social determinants of health should only be reported as secondary diagnoses. See Section I.C.21.c.17 for additional information regarding coding social determinants of health.

Under Guideline No. 18, Use of Sign/Symptom/Unspecified Codes of the General Coding Guidelines, there was a new paragraph added to the guidance:

  • As stated in the introductory section of these official coding guidelines, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

Within section I.C. for chapter-specific guidelines is where you’ll locate some additions in Chapter 1, Certain Infectious and Parasitic Diseases. Guidelines for the coding of COVID-19 includes the following changes, highlighted in bold:

g) Signs and symptoms without definitive diagnosis of COVID-19. For patients presenting with any signs/symptoms associated with COVID-19 (such as fever, etc.), but a definitive diagnosis has not been established, assign the appropriate code(s) for each of the presenting signs and symptoms, such as: • R05.1, Acute cough, or R05.9, Cough, unspecified • R06.02 Shortness of breath • R50.9 Fever, unspecified

Here we also find the new “post-COVID-19” guidance, which will be very helpful. The new guideline addition (I.C.1.g1.m) includes the following:

  • (m) Post-COVID-19 Condition. For sequela of COVID-19, or associated symptoms or conditions that develop following a previous COVID-19 infection, assign a code(s) for the specific symptom(s) or condition(s) related to the previous COVID-19 infection, if known, and code U09.9, Post COVID-19 condition, unspecified.
  • Code U09.9 should not be assigned for manifestations of an active (current) COVID-19 infection.
  • If a patient has a condition(s) associated with a previous COVID-19 infection and develops a new active (current) COVID-19 infection, code U09.9 may be assigned in conjunction with code U07.1, COVID-19, to identify that the patient also has a condition(s) associated with a previous COVID-19 infection. Code(s) for the specific condition(s) associated with the previous COVID-19 infection and code(s) for manifestation(s) of the new active (current) COVID-19 infection should also be assigned.

Note that Chapter 22 does not contain the guideline for post-COVID-19 conditions, even though the code is referenced there (U09.9, Post-COVID-19 condition, unspecified; see Section I.C.1.g.1.m). Now is the time to read through the COVID-19 guidelines carefully.

Be sure to also read over the guideline revisions in Chapter 4 relating to diabetes and the use of insulin, oral hypoglycemics, and injectable non-insulin drugs, as well as the Chapter 5, Mental, Behavioral, and Neurodevelopmental Disorders regarding psychoactive substance use, unspecified; medical conditions due to psychoactive substance use, abuse and dependence; and blood alcohol level. Also, carefully review the Chapter 21 section on the social determinants of health (SDoH).

This article does not cover all of the guideline changes, but rather gives you a taste of them, so it’s an imperative that health information management (HIM) and clinical documentation integrity (CDI) professionals read over the complete set.  In addition, obtaining education regarding the new ICD-10-CM codes is a sensible complementary step. It’s time to learn so that we can have accurate and compliant coding.

Note that the effective date for the FY 2022 Official Guidelines is Oct. 1, 2021, same as for the FY 2022 ICD-10-CM/PCS code changes.


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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