2023 ICD-10-CM Guideline Changes

View the ICD-10-CM Guideline Changes for 2023
  
Chapter 19 (Injury, poisoning, and certain other consequences of external causes [S00-T88])

The guidelines clarify that coders do not need to see a change in the patient’s condition to assign an underdosing code. According to the updated guidelines, “Documentation that the patient is taking less of a medication than is prescribed or discontinued the prescribed medication is sufficient for code assignment.”

15 new codes were added to ICD-10-CM category Z79 (long-term [current] drug therapy), including Z79.85 (long-term [current] use of injectable non-insulin antidiabetic drugs). A new guideline was added to Chapter 4 (Endocrine, Nutritional, and Metabolic Diseases) advising that if the patient is treated with both insulin and an injectable non-insulin antidiabetic drug, assign codes Z79.4 (long-term [current] use of insulin) and Z79.85 (long-term [current] use of injectable non-insulin antidiabetic drugs). If the patient is treated with both oral hypoglycemic drugs and an injectable non-insulin antidiabetic drug, assign codes Z79.84 (long-term [current] use of oral hypoglycemic drugs) and Z79.85.

Changes in the guidelines are in Bold
B. General Coding Guidelines

B, 14. Documentation by Clinicians Other than the Patient's Provider
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.
Added: Underimmunization status

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.

16. Documentation of Complications of Care:  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.

C. Chapter-Specific Coding Guidelines,

C,1,2), (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.

(b) Patient with HIV disease admitted for unrelated condition
(i) HIV managed by antiretroviral medication
If a patient with documented HIV disease, HIV-related illness or AIDS is currently managed on antiretroviral medications, assign code B20, Human immunodeficiency virus [HIV] disease. 

d. Sepsis, Severe Sepsis, and Septic Shock Infections resistant to antibiotics
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.

Chapter 2: Neoplasms (C00-D49) 
a. Admission/Encounter for treatment of primary site If the malignancy is chiefly responsible for occasioning the patient admission/encounter and treatment is directed at the primary site, designate the primary malignancy as the principal/first-listed diagnosis. The only exception to this guideline is if the administration of chemotherapy, immunotherapy or external beam radiation therapy is chiefly responsible for occasioning the admission/encounter. In that case, assign the appropriate Z51.-- code as the first-listed or principal diagnosis and the underlying diagnosis or problem for which the service is being performed as a secondary diagnosis. 

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.

4. Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89)
3) Diabetes mellitus and the use of insulin, oral hypoglycemic, and injectable non-insulin drugs

If the patient is treated with both oral hypoglycemic drugs 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. 

If the patient is treated with both insulin and an injectable non-insulin antidiabetic drug, assign codes Z79.4, Long term (current) use of insulin, and Z79.85, Long-term (current) use of injectable non-insulin antidiabetic drugs.

If the patient is treated with both oral hypoglycemic drugs and an injectable non-insulin antidiabetic drug, assign codes Z79.84, Long term (current) use of oral hypoglycemic drugs, and Z79.85, Long-term (current) use of injectable non-insulin antidiabetic drugs.

(a) Secondary diabetes mellitus and the use of insulin, oral hypoglycemic drugs, or injectable non-insulin drugs.

If the patient is treated with both oral hypoglycemic drugs 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.

If the patient is treated with both insulin and an injectable non- insulin antidiabetic drug, assign codes Z79.4, Longterm (current) use of insulin, and Z79.85, Long-term (current) use of injectable non-insulin antidiabetic drugs.

If the patient is treated with both oral hypoglycemic drugs and an injectable non-insulin antidiabetic drug, assign codes Z79.84, Long-term (current) use of oral hypoglycemic drugs, and Z79.85, Long-term (current) use of injectable noninsulin antidiabetic drugs.

5. Chapter 5: Mental, Behavioral and Neurodevelopmental disorders
(F01 – F99)
b.,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.

15. Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)
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.

i. Gestational (pregnancy induced) diabetes
Long-term (current) use of insulin, Z79.84, Long-term (current) use of oral hypoglycemic drugs, and Z79.85, Long-term (current) use of injectable non-insulin antidiabetic drugs, should not be
assigned with codes from subcategory O24.4.

4) Hemorrhage following elective abortion
For hemorrhage post elective abortion, assign code O04.6, Delayed or excessive hemorrhage following (induced) termination of pregnancy. Do not assign code O72.1, Other immediate postpartum hemorrhage, as this code should not be assigned for post abortion conditions. Do not assign code Z33.2, Encounter for elective termination of pregnancy, when the patient experiences a complication post elective abortion. 

c. Categories of Z Codes

14) Miscellaneous Z Codes
Z73 Problems related to life management difficulty Note: These codes should be assigned only when the documentation specifies that the patient has an associated problem.

10) Code Z71.87, Encounter for pediatric-to-adult transition counseling, should be assigned when pediatric-to-adult transition counseling is the sole reason for the encounter or when this counseling is provided in addition to other services, such as treatment of a chronic condition.

If both transition counseling and treatment of a medical condition are provided during the same encounter, the code(s) for the medical condition(s) treated and code Z71.87 should be assigned, with sequencing depending on the circumstances of the encounter.

q. Termination of Pregnancy and Spontaneous abortions

4) Hemorrhage following elective abortion
For hemorrhage post elective abortion, assign code O04.6, Delayed or excessive hemorrhage following (induced) termination of pregnancy. Do not assign code O72.1, Other immediate postpartum hemorrhage, as this code should not be assigned for post-abortion conditions. Do not assign code Z33.2, Encounter for elective termination of pregnancy, when the patient experiences a complication post elective abortion. 

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