Fiscal year 2023 is here with several important updates and additions to the ICD-10-CM Official Guidelines for Coding and Reporting. These guideline changes apply to discharges and patient encounters occurring October 1^st of 2022 through September 30^th of 2023. Chapter-specific guideline changes will be reviewed in this blog but be sure to check out my previous blog “ICD-10-CM General Guideline Updates for FY2023” to review the General Guideline updates for 2023.

Guideline Revisions for Hemolytic-uremic Syndrome (HUS)

Hemolytic-uremic syndrome (HUS) takes center stage for FY2023 as this condition is the focus of both HIV and sepsis guideline revisions.

Hemolytic-uremic syndrome is a disorder characterized by thrombocytopenia, microangiopathic hemolytic anemia and acute kidney injury. This condition is typically associated with certain strains of E. coli, with diarrhea and upper respiratory infections being the most common factors leading to HUS.

Hemolytic-uremic Syndrome and HIV

As we know, when a patient is admitted for an HIV-related condition, B20 (Human immunodeficiency virus [HIV] disease) should be sequenced as the principal diagnosis, followed by additional diagnosis codes for the HIV-related condition(s).

However, this guideline has been updated for FY2023 with an exception. If the reason for admission is hemolytic-uremic syndrome associated with HIV disease, D59.31, Infection-associated hemolytic-uremic syndrome should be assigned as the principal diagnosis, with B20 as an additional diagnosis.

I.C.1.a.(2), Selection and sequencing of HIV codes

(a) Patient admitted for HIV-related condition

“If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, Human immunodeficiency virus [HIV] disease followed by additional diagnosis codes for all reported HIV-related conditions.

An exception to this guideline is if the reason for admission is hemolytic-uremic syndrome associated with HIV disease. Assign code D59.31, Infection-associated hemolytic-uremic syndrome, followed by code B20, Human immunodeficiency virus [HIV] disease.”

Hemolytic-uremic Syndrome and Sepsis

A new sepsis guideline also instructs coding professionals to assign hemolytic-uremic syndrome as the principal diagnosis when associated with sepsis:

I.C.1.d.9) Hemolytic-uremic syndrome associated with sepsis

“If the reason for admission is hemolytic-uremic syndrome that is associated with sepsis, assign code D59.31, Infection-associated hemolytic-uremic syndrome as the principal diagnosis. Codes for the underlying systemic infection and any other conditions (such as severe sepsis) should be assigned as secondary diagnoses.”

Neoplasms

A new guideline regarding secondary malignant neoplasm of lymphoid tissue has been added to the neoplasm chapter. Normally, a malignancy that spreads to a secondary site would be found in codes C76-80 (Malignant neoplasms of ill-defined, other secondary and unspecified sites). However, if a lymphoid cancer spreads beyond the lymph nodes, a code from categories C81-C85 with a final character “9” should be assigned identifying “extranodal and solid organ sites”, rather than a code for the secondary neoplasm.

I.C.2.a.t. Secondary malignant neoplasm of lymphoid tissue

“When a malignant neoplasm of lymphoid tissue metastasizes beyond the lymph nodes, a code from categories C81-C85 with a final character “9” should be assigned identifying “extranodal and solid organ sites” rather than a code for the secondary neoplasm of the affected solid organ. For example, for metastasis of B-cell lymphoma to the lung, brain and left adrenal gland, assign code C83.39, Diffuse large B-cell lymphoma, extranodal and solid organ sites.”

Dementia

Dementia underwent a significant expansion for FY2023 with the addition of 87 new codes and a new guideline regarding dementia severity (unspecified, mild, moderate or severe). The guideline also explains that if a patient is admitted with one severity and progresses, only the highest severity level is reported.

I.C.5.d. Dementia

“The ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the etiology and severity (unspecified, mild, moderate or severe). Selection of the appropriate severity level requires the provider’s clinical judgment and codes should be assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting), unless otherwise instructed by the classification. If the documentation does not provide information about the severity of the dementia, assign the appropriate code for unspecified severity.

If a patient is admitted to an inpatient acute care hospital or other inpatient facility setting with dementia at one severity level and it progresses to a higher severity level, assign one code for the highest severity level reported during the stay.”

Completed Weeks of Gestation

Completed weeks of gestation refers to full weeks and a guideline has been added indicating as such. For example, if a patient is 39 weeks and 6 days, then the code for 39 weeks of gestation is coded, as the patient has not yet reached 40 completed weeks. The guideline also aligns with a question submitted to Coding Clinic (2^nd Qtr. 2022 Pages: 3-4) asking for clarification on “completed weeks of gestation.”

I.C.15.a.7.) Completed weeks of gestation

“In ICD-10-CM, “completed” weeks of gestation refers to full weeks. For example, if the provider documents gestation at 39 weeks and 6 days, the code for 39 weeks of gestation should be assigned, as the patient has not yet reached 40 completed weeks.”

Underdosing

ICD-10-CM Official Guidelines define underdosing as taking less of a medication than is prescribed by a provider or a manufacturer’s instruction and/or discontinuing the use of a prescribed medication on the patient’s own initiative (not directed by the patient’s provider). The guideline has been expanded for 2023 to clarify that documentation of a change in the patient’s condition is not required in order to assign an underdosing code. Documentation that the patient is taking less of a medication than is prescribed, or discontinued the prescribed medication is sufficient for code assignment.

I.C.19.e.5.(c) Underdosing

“Underdosing refers to taking less of a medication than is prescribed by a provider or manufacturer’s instruction. Discontinuing the use of a prescribed medication of the patient’s own initiative (not directed by the patient’s provider) is also classified as an underdosing. For underdosing, assign the code from categories T36-T50 (fifth or sixth character “6”).

Documentation of a change in the patient’s condition is not required in order to assign an underdosing code.

Documentation that the patient is taking less of a medication than is prescribed or discontinued the prescribed medication is sufficient for code assignment.”

Social Determinants of Health

Guidance regarding Social Determinants of Health (SDOH) has been updated, clarifying that these codes are to be used only when documentation specifies there are problems arising from the SDOH or if it poses a risk. The guideline update provides several helpful and specific examples, including an example of when it would be (and would not be) appropriate to assign Z60.2, Problems related to living alone.

17) Social Determinants of Health

“Social determinants of health (SDOH) codes describing social problems, conditions, or risk factors that influence a patient’s health should be assigned when this information is documented in the patient’s medical record. Assign as many SDOH codes as are necessary to describe all the social problems, conditions, or risk factors documented during the current episode of care. For example, a patient who lives alone may suffer an acute injury temporarily impacting their ability to perform routine activities of daily living. When documented as such, this would support assignment of code Z60.2, Problems related to living alone. However, merely living alone, without documentation of a risk or unmet need for assistance at home, would not support assignment of code Z60.2.

Documentation by a clinician (or patient-reported information that is signed off by a clinician) that the patient expressed concerns with access and availability of food would support assignment of code Z59.41, Food insecurity. Similarly, medical record documentation indicating the patient is homeless would support assignment of a code from subcategory Z59.0-, Homelessness.”

Reminder:

SDOH code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider (e.g., social workers, case managers, nurses) since this information represents social information, rather than medical diagnoses.

Patient self-reported documentation may also be used to assign codes for SDOH as long as signed-off by and incorporated into the medical record by either a clinician or provider.

While key changes to the chapter specific guideline updates have been reviewed in this blog, be sure to review both the guidelines in their entirety and the new ICD-10-CM codes to ensure you are assigning the most appropriate codes. The complete ICD-10-CM Official Guidelines for Coding and Reporting FY 2023 can be found on the CMS website by visiting the following link: https://www.cms.gov/files/document/fy-2023-icd-10-cm-coding-guidelines.pdf

Additional Information

Additional information regarding Chapter-Specific Guideline Updates for FY2023 can be found below:

• “Hemolytic Uremic Syndrome”https://www.hopkinsmedicine.org/health/conditions-and-diseases/hemolytic-uremic-syndrome
• “Pathophysiology of HUS”https://www.merckmanuals.com/professional/hematology-and-oncology/thrombocytopenia-and-platelet-dysfunction/hemolytic-uremic-syndrome-hus
• AHA Coding Clinic, 4^thQuarter 1993 Page: 25 Syndrome, hemolytic uremic
• AHA Coding Clinic, 4^thQuarter 2022 Pages: 14-15 Dementia: stage or severity, behavioral and physical symptoms
• AHA Coding Clinic, 2^nd2022 Pages: 3-4 Determining completed weeks of gestation