Just released on Thursday, Aug. 10 are the Official ICD-10-CM/PCS Coding and Reporting Guidelines for the 2018 fiscal year, totaling 117 pages. The National Center for Health Statistics, via the CDC (Centers for Disease Control and Prevention), has posted the guidelines on its website here: https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf.
Readers should note that the time frame to which these guidelines apply to is Oct. 1, 2017 to Sept. 30, 2018.
When you review the guidelines for this coming fiscal year, please note the following:
The conventions for ICD-10-CM are the general rules for use of the classification independent of the guidelines, and there remain 19 of these conventions, as in the FY 2017 guidelines. Convention No. 15, “with,” does have some revised narrative, so every coding professional should read this over carefully. Here’s a portion of this revision, highlighted in blue font:
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, or an instructional note in the 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”).
For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related.
In convention No. 17, the “code also” note, there is also a revision to note:
A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.
Again, each coding professional in every setting and role should read over the full set of guidelines. This not only is a duty and responsibility, but it also will assist in coding accurately. Reference: https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf
PROGRAM NOTE:
Make certain that your facility will be in compliance with the new ICD-10 code changes being made effective Oct. 1, 2017. Register now to attend a three-part webcast workshop series, with installments scheduled for Aug. 16, 23, and 30. Produced by ICD10monitor, the series will feature Scot Nemchik, CCS, and Janice Tarlecki, MBA, RHIA, CCS, both with Ciox Health. Register now.
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EDITOR’S NOTE: This series is based on the “Developing Facility-Specific Coding Guidelines” which is an AHIMA Practice Brief. This practice brief was updated in December
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