Several important updates and additions were made to the ICD-10-CM Official Guidelines for Coding and Reporting for fiscal year 2022. Although key changes will be highlighted in this article, be sure to review the new and revised guidance in its entirety to ensure proper diagnosis coding and reporting. Additionally, visit our blogs about 9 Tips to Calm Coder Anxiety, ICD-10 Implementation Process, ICD-10 Readiness, ICD-10-PCS for venous access lines and catheters, vaginal deliveries, and angiography.

General Guideline Updates

Guideline I.B.2, Level of Detail in Coding has been expanded to reiterate the importance of reporting diagnosis codes to both the highest number of characters available and the highest level of specificity that is documented in the medical record.

I.B.2. 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.”

A new paragraph was added to Guideline I.B.13, Laterality. We are now able to assign laterality based on documentation by clinicians other than the patient’s provider. Note that the “unspecified” side should rarely be used, and if there is conflicting documentation of the laterality in the record, the attending provider should be queried.

I.B.13, Laterality

“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.”

Clarification is given regarding Guideline I.B.14, Documentation by Clinicians Other than the Patient’s Provider, including specification of situations where code assignment may be based on documentation by other healthcare providers. The list of exceptions also includes two new exceptions– laterality and blood alcohol level.

I.B.14. Documentation by Clinicians Other than the Patient’s Provider

“… 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”

Chapter-Specific Guideline Updates

One of the major chapter-specific guideline updates can be found in I.C.1.a.(i), History of HIV managed by medication. The new guideline clarifies that if a patient has a documented history of HIV disease which is currently being managed with antiretroviral medications, code B20, HIV disease should be reported.

I.C.1.a.(i), History of HIV managed by medication

“If a patient with documented history of HIV disease is currently managed on antiretroviral medications, assign code B20, Human immunodeficiency virus [HIV] disease. Code Z79.899, Other long term (current) drug therapy, may be assigned as an additional code to identify the long-term (current) use of antiretroviral medications.”

Chapter 1 also includes new “post-COVID-19” guidance as well as updated guidance on multisystem inflammatory syndrome. Guideline I.C.1.g.(l) is revised to include the new code U09.9 (Post COVID-19 condition, unspecified) and gets rid of the instruction regarding the B94.8 sequelae code.

I.C.1.g.(l) Multisystem Inflammatory Syndrome

“If MIS develops as a result of previous COVID-19 infection, assign codes M35.81, Multisystem inflammatory syndrome, and B94.8, Sequelae of other specified and infectious diseases.

If an individual with a history of COVID-19 develops MIS and the provider does not indicate whether the MIS is due to the previous COVID-19 infection, assign codes M35.81, Multisystem inflammatory syndrome, and Z86.16, Personal history of COVID-19 U09.9, Post COVID-19 condition, unspecified.”

Guideline I.C.1.g.(m) further explains that for a sequela of COVID-19 (or associated symptoms or conditions that develop following a previous COVID-19 infection), U09.9, Post COVID-19 condition, unspecified should be coded as well as a code for the specific symptom or condition. The guideline also states that code U09.9 should not be assigned for manifestations of an active/current COVID-19 infection.

(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.”

A new guideline has been added to Chapter 2 regarding breast implant associated anaplastic large cell lymphoma (BIA-ALCLC). The guideline clarifies that even though BIA-ALCLC is associated with an implant, a complication code should not be assigned. Instead, we are instructed to assign the new code C84.7A.

I.C.2.(s) Breast Implant Associated Anaplastic Large Cell Lymphoma

“Breast implant associated anaplastic large cell lymphoma (BIA-ALCL) is a type of lymphoma that can develop around breast implants. Assign code C84.7A, Anaplastic large cell lymphoma, ALK-negative, breast, for BIAALCL. Do not assign a complication code from chapter 19.”

In Chapter 4, a guideline revision now directs us to capture the ICD-10-CM codes for both insulin and any other antidiabetic medications, such as oral hypoglycemic drugs and non-insulin injectable medications.

I.C.4.3. Diabetes mellitus and the use of insulin, oral hypoglycemics, and injectable non-insulin drugs

“If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11-, Type 2 diabetes mellitus, should be assigned. Additional code(s) should be assigned from category Z79 to identify the long-term (current) use of insulin, oral hypoglycemic drugs, or injectable non-insulin antidiabetic, as follows:

If the patient is treated with both oral medications and insulin, both code Z79.4, Long term (current) use of insulin, and code Z79.84, Long term (current) use of oral hypoglycemic drugs, should be assigned.”

Chapter 12 includes a new paragraph which has been added to I.C.12.a.2 regarding unstageable pressure ulcers. The guideline clarifies that if the stage of an unstageable ulcer is revealed after debridement, only the code for the specific stage revealed after the debridement should be assigned.

I.C.12.a.2. Unstagable pressure ulcers

“If during an encounter, the stage of an unstageable pressure ulcer is revealed after debridement, assign only the code for the stage revealed following debridement.”

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 2022 can be found on the CMS website. For more information on medical coding, visit our coding tips blog, coder education blog, or contact us today to see how MRA can help optimize your organization’s coding needs.