WOW! The FY2022 Official Guidelines for Coding and Reporting were released on July 12^th, 2021, which was earlier than expected. The big topic within the guidelines is the Post COVID-19 guidance. Plus, there are several other additions/changes in the General Coding Guidelines which should be reviewed carefully. This blog will cover “some” of the changes, additions, revisions, but is not a representation of all the FY2022 guidelines changes.

Starting with the “General Coding Guidelines” section there are some changes/additions that are noteworthy. For example, guideline #2 (bold wording represents the change/revision): Level of Detail in Coding Diagnosis codes are to be used and reported at their highest number of characters available and to the highest level of specificity documented in the medical record.

Guideline #13 Laterality, has the following addition:

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.

And Guideline #14 Documentation by Clinicians Other than the Patient’s Provider has changes/revisions also:

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.

Within section I.C. for “Chapter Specific Guidelines” is where you will locate several additions starting in Chapter 1 Certain Infectious and Parasitic Diseases, for the coding of Coronavirus Infection, COVID-19 and Post COVID-19 which includes the following changes (bolded wording represents a change/revision):

1. 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

The new “Post COVID-19” guidance is I.C.1.g1.m, and 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.

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 review closely Chapter 21 section on Social Determinants of Health (SDOH) as there are some additions here as well.

In addition to reading through the guidelines, it is important to receive some formal education on the new ICD-10-CM codes themselves and these FY2022 Official Guidelines. Be sure to allow time for you and your staff to attend and/or obtain this valuable education on both the ICD-10-CM code changes and the Official Guidelines. The link to the Official Guidelines for Coding and Reporting FY2022 full document is at the CDC website towards the bottom of the page: https://www.cdc.gov/nchs/icd/icd10cm.htm