The Inpatient Prospective Payment System (IPPS) Final Rule for the 2021 fiscal year has been finalized, including updates to the guidelines that need to be implemented for ICD-10-CM and PCS. The following is an overview of what’s in store for guideline changes, come Oct. 1.

For ICD-10-CM, there are 14 new and eight revised guidelines. Thirteen of the new guidelines, not surprisingly, provide direction related to the coding and reporting of COVID-19 infection, with the additional new guideline providing direction for coding of vaping-related disorders.

Eleven of the new COVID-19 guidelines will be located in the guidelines for Chapter 1, Certain Infectious and Parasitic Diseases, with new guidelines for coding of COVID-19 infection in pregnancy, childbirth, and the puerperium, and in newborns. These are being added to the guidelines for ICD-10-CM chapters with codes for reporting conditions in those populations: Chapters 15 and 16, respectively.

Two notable guideline revisions include:

  • Language being added to General Coding Guideline I.B.14, Documentation by Clinicians Other than the Patient’s Provider, specifying that self-reported documentation may also be used to assign codes for the social determinants of health (SDoH), as long as the information is signed off on and incorporated into the health record by either a clinician or provider.
  • Additions to Guideline I.C.4.a.3, Diabetes Mellitus and the use of Insulin and Oral Hypoglycemics, will now include injectable non-insulin drugs, which has implications regarding the assignment of long-term drug-use Z codes when a patient is being treated with both insulin and injectable non-insulin drugs.

In ICD-10-PCS, there were two new guidelines added and two guidelines revised for 2021. Three of the updates are being made to Section B3, which includes the guidelines for root operations, and a new guideline is being added to Section B5, Approach.

New Guideline B3.18 Excision/Resection, followed by replacement, relates to replacement procedures performed once a body part has been excised or resected. The guideline indicates that codes should be assigned to report both the excision/resection and the replacement procedure, so each distinct objective is captured, except when the excision or resection is considered integral and preparatory for the replacement procedure, such as in total joint replacement.

Guideline B3.10c has been revised to specify that the use of bone graft or bone graft substitute is required to accomplish spinal fusion via insertion of an interbody spinal fusion device.

The new approach Guideline B2.5b clarifies that when incisions made to insert an endoscope are extended to assist in removal of all or a portion of a body part, the appropriate approach value for the procedure is still Percutaneous Endoscopic.

For a full review of the 2021 updates, be sure to attend ICD10monitor’s 2021 IPPS Final Rule coding webcast series, featuring Laurie Johnson.


Cari Greenwood, RHIA, CCS, CPC, CICA

Cari is an independent consultant with more than 18 years of experience in coding and revenue cycle management. Her experience includes inpatient and facility/professional fee outpatient coding and auditing. She also applies her coding and auditing expertise to instruction and training, client support and curriculum development. Cari earned a post-baccalaureate certificate in health information management from Weber State University.

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