What’s Up with the Updates: 2022 ICD-10-CM Official Coding and Reporting Guidelines

Coders, CDISs and physician advisors should review the new guidelines.

I thought I would share some thoughts about the updates to the 2022 ICD-10-CM Coding and Reporting Guidelines (https://www.cms.gov/files/document/fy-2022-icd-10-cm-coding-guidelines.pdf) with you. None of the edits seem shocking. I think most of them are just clarifications, and some fall into the category of “it’s hard to believe they had to say that explicitly.” Perhaps codifying these points will prevent auditors from using them against us. Let me run through them.

• In the General Coding Guidelines, I.B.2., to the sentence that ‘diagnosis codes are to be reported with the highest number of characters available,’ they added that the codes should reflect the highest level of specificity documented in the medical record. A similar instruction was added to the outpatient section. This seems obvious to me, but I think it is addressing situations where a higher level of specificity is documented in the daily progress note or in the body of the encounter, and then the provider lapses or backslides in the discharge summary or diagnosis section. An example might be acute tubular necrosis is diagnosed, but the discharge summary just says AKI, acute kidney injury.
• When laterality is not provided in situations which warrant it, CMS is punishing bad behavior by eliminating comorbidity status for laterality-unspecified conditions. Section I.B.13., Laterality, has a new paragraph stating that laterality may be derived from medical record documentation from clinicians other than the patient’s primary provider. If there is conflicting documentation, the attending is to be queried, as is customary. The guidelines instruct that “unspecified” side should be used only under very limited circumstances when clarification is not possible.
• The next edit clarifies that “clinicians” scenario. I.B.14., Documentation by Clinicians Other than the Patient’s Provider, specifies the situations where other healthcare providers are permitted to provide documentation for the assignment of codes. These are frequently elements which are related to diagnoses which the provider has made but neglected to include details, such as Body Mass Index (BMI), depth or stage of ulcers, and Glasgow Coma Score. The guidelines now list the exceptions in an organized fashion, and blood alcohol level and laterality are explicitly named. Acceptable “clinicians” are involved in the care of the patient, e.g., dietitian, wound nurse, EMT, social worker, but are not necessarily healthcare workers whose documentation is normally picked up by a coder.
• I found it interesting that the 2021 edit of “Patient self-reported documentation may be used to assign codes for social determinants of health (SDoH), as long as (it) is signed-off by and incorporated into the health record by either a clinician or provider” was eliminated in the newest iteration.
• In Section I.B.18., Use of Sign/Symptom/Unspecified Codes, a paragraph was introduced to emphasis that consistent, complete documentation is essential for accurate code assignment and reporting of diagnoses and procedures. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated. I don’t know what the impetus of the addition of this was – as the paragraph notes, this is all stated in the introductory section of the coding guidelines. I guess some people need to be reminded that you shouldn’t just take the easy route and stall at signs and symptoms?
• On page 18, I.B.19.d., Use of Z codes, adds that Z codes are appropriate to be captured if there is “additional information relevant to a patient encounter.” My interpretation is that those Z codes (often SDoH) may not be evaluated, treated, or increase length of stay during this admission, but they may have significant impact on the patient’s baseline condition and influence discharge/outpatient management.
• I appreciate the addition of the phrase, “if applicable,” in I.C.1.a.2.h. [i.e., Use additional codes for any associated high-risk behavior, if applicable]. There was an implied association of high-risk behavior with HIV previously.
• One of the most important edits in 2022, in my opinion, is the added I.C.1.a.2.i., History of HIV managed by medication. Clinically, we strive for, and now have the medically technology to achieve, U=U (Undetectable = Untransmittable). That may be confounding for coders. Once a patient has had documented HIV-induced disease, even if medications eradicate all virus and any conditions which arose from the HIV infection, the patient can’t revert to Z21, HIV status, even if they are effectively asymptomatic. The rule is once B20 (HIV disease), always B20.
• The COVID-19 section has had some edits, no surprise there.
  • o Signs and symptoms without definitive diagnosis of COVID-19 has been revised to reflect new cough ICD-10-CM specificity.
  • o Personal history of COVID-19 is stressed to be “without residual symptom(s) or condition(s)” in I.C.1.g.1.j. If the patient is following up and still has any symptom or condition related to a previous COVID-19 infection, U09.9 is the go-to code.
  • o Multisystem Inflammatory Syndrome (MIS) is expanded upon, detailing the sequencing and relationship with current COVID-19, post COVID-19 condition, and exposure to COVID-19 without known infection.
  • o Explanation of how to use U09.9, Post COVID-19 condition, unspecified, is found in I.C.1.g.1.m. If there are sequela or persistent symptoms or conditions following a previous (and not considered current) COVID-19 infection, U09.9 is the correct code. In anticipation of coding patients who have a previous infection and have been reinfected with another case of COVID-19, there is instruction that U09.9 may be used in conjunction with U07.1.
• A glaring deficiency in diabetes coding is rectified in the 2022 guidelines. If a patient was maintained on insulin and oral hypoglycemic medication, instructions had previously been to only code the long-term use of insulin. In 2022, we are directed to capture in ICD-10-CM codes both the insulin and any other antidiabetic medications such as oral hypoglycemics or injectable non-insulin medications.
• I am not satisfied with the attempted clarification of medical conditions due to psychoactive substance use, abuse, and dependence. They are trying to settle the question as to whether conditions which are not mental health-related in nature (as opposed to psychosis, insomnia, mood disorder, anxiety, etc.) but are alcohol-induced should utilize F10.- codes. The example they use is K85.2, but this is a bad example because it has “Alcohol-induced” embedded in the title. An F10.- alcohol-induced disorder designation would be redundant. However, there are other non-mental-health diagnoses, like Wernicke’s encephalopathy or Dupuytren’s contracture, which can be alcohol-induced and that information might be very useful for epidemiological purposes. But until they either create an F10.- code that signifies alcohol use disorder with alcohol-induced non-mental-health condition or recommend use of “other alcohol-induced disorder” for those situations, the guideline is to use the alcohol use disorder, uncomplicated code with the other resultant condition effectively being unlinked to the alcohol.
• In I.C.5.b.5., Blood Alcohol Level, we are given permission to pick up the blood alcohol level from Y90 from another clinician if the provider has documented a condition from F10. My impression is that the coder can’t just pick up the level from the laboratory results (like a positive COVID-19 test).
• In Obstetrics section, the guidelines clarify that if there is not an “in childbirth” option for an obstetric complication occurring during an admission during which delivery occurs, the code is assigned “describing the current trimester.” I presume that dovetails into the subsequent guideline which instructs that you assign the trimester in which the condition arose if the admission encompasses more than one trimester.
• Last year, the guidelines specified that Glasgow Coma Scores (GCS) were only to be assigned for traumatic brain injury (TBI). In 2022, in I.C.18.e., the guideline that R40.20, Unspecified coma, is permitted to be used with any medical condition is put forth. They limit the coma scale codes to R40.21- to R40.24- in order to exclude R40.20 from the only-TBI instruction.
• GCS has a final character that specifies when the score was obtained. Once in the hospital, you only have a choice of at admission and 24 hours or more after admission. If there are multiple scores performed in the first 24 hours, you only capture the one at admission.
• Total body surface area of burns is only for acute burns and corrosions. You do not specify this percentage for subsequent or sequelae.
• The reason for an encounter, such as screening or counseling, is sequenced first and then any personal or family history codes may be assigned as additional diagnoses.
• I am not sure that the guidance regarding the new code, Z71.85, Encounter for immunization safety counseling, really sheds enough light. The guidelines edit says that it is for “counseling of a patient or caregiver regarding the safety of a vaccine,” but “it is not for the provision of general information regarding risks and potential side effects during routine encounters for the administration of vaccines.” Clearly this is to cover detailed discussions about COVID-19 vaccination or to attempt to overcome any other vaccine hesitancy. The American Academy of Pediatrics requested this new code, and it is intended to be used with Z23, Encounter for immunization or Z28.-, Immunization not carried out and underimmunization status.
• An entirely new subsection, I.C.21.c.17., details SDoH. It states that SDoH should be coded when documented, and that the documentation may come from personnel other than healthcare providers, such as social workers, community health workers, case managers, or nurses. SDoH codes are primarily found in Z55-Z65.

I hope my assessment has been helpful, but you will need to read the updates for yourself. I highly recommend that all coders, CDISs, and physician advisors review the ICD-10-CM Official Guidelines for Coding and Reporting every year when they are updated. Independent of the revisions, it is always good to review the guidelines we should be familiar with and utilizing all the time.

Programming Note: Listen to Dr. Erica Remer when she co-hosts Talk Ten Tuesdays with Chuck Buck, Tuesdays, 10 Eastern.