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 1st of 2022 through September 30th of 2023. Although general guideline updates will be discussed in this blog, so be sure to review the new and revised guidance in its entirety to ensure proper diagnosis coding and reporting. Stay tuned for my next blog, which will go over the chapter-specific guideline updates for FY2023.
Code Assignment and Clinical Criteria
Guideline A.19., Code assignment and clinical criteria, states that if a provider documents the patient has a particular condition, the provider’s statement is sufficient- regardless of the clinical criteria used by the provider to arrive at the diagnosis. This guidance has not changed. However, verbiage has been added to the end of the guideline, stating that if there is conflicting medical record documentation, the provider should be queried.
I.A.19. Code assignment and clinical criteria
“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider.
Underimmunization Status
Underimmunization status has joined the list of exceptions in Guideline B.14., Documentation by Clinicians Other Than the Patient’s Provider. Underimmunization status may be reported based on medical record documentation from clinicians who are not the patient’s provider.
I.B.14, Documentation by Clinicians Other than the Patient’s Provider
“Code assignment is based on the documentation by the patient’s provider (i.e., the 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 professional legally accountable for establishing the patient’s diagnosis). In this context, “clinicians” other than the patient’ provider refer to healthcare professionals permitted, based on regulatory or accreditation requirements or internal hospital policies, to document the patient’s official medical record. These exceptions include codes for:
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- 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
- Underimmunization status
This information is typically, or may be, documented by 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, codes for social determinants of health and underimmunization status should only be reported as secondary diagnoses.”
Reminder!
New ICD-10-CM codes were created for underimmunization status, which went into effect April 1st of 2022.
New codes for underimmunization for COVID-19 status:
- 310 Unvaccinated for COVID-19
- 311 Partially vaccinated for COVID-19
New code for other underimmunization status:
- 39 Other underimmunization status
Documentation of Complications of Care
B.16. Documentation of Complications of Care has been updated to clarify that although documentation must support a cause-and-effect relationship between the care provided and the condition, it is not necessary for the provider to explicitly document the term “complication.” The guideline update aligns with Coding Clinic updates regarding complications of care (Coding Clinic, Second Quarter 2021, Page 8 and First Quarter 2022, Pages: 50-51).
B.16. Documentation of Complications of Care
“Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and the documentation must support that the condition is clinically significant. It is not necessary for the provider to explicitly document the term “complication.” For example, if the condition alters the course of the surgery as documented in the operative report, then it would be appropriate to report a complication code. Query the provider for clarification if the documentation is not clear as to the relationship between the condition and the care or procedure.”
Be sure to review the guidelines in their entirety 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 or by clicking here.
