The ICD-10-CM Official Guidelines for Coding and Reporting is effective Oct. 1 through Sept. 30. That means the updated guidelines for fiscal year 2019 have been in effect for a month, already, by the time this issue makes it to your mailbox (or inbox). Changes include a new coding guideline in the Coding Guidelines section; updates to guidelines I.B.19 (a, b, c, and d) and I.C.5.c; and new instruction regarding “with” and sepsis coding. A review of the updated guidelines is necessary to ensure coding compliance.

Guideline I.A.15 Gets More Specific

The guideline at section I.A.15 now specifies:

The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List.

This changes the Alphabetic Index to include such diseases as diabetes mellitus (DM) with certain complications. For example, DM under “with” complications instructs that the conditions are automatically linked and do not have to be indicated by the physician. The guideline specifies that we may use the DM codes “unless the documentation clearly states the conditions are unrelated.” This includes:

Diabetes with:

foot ulcer: E11.621

neurologic complication: E11.49

periodontal disease: E11.630

Guideline I.B.14 Clarifies Documentation by Others

The guideline for section I.B.14 has changed, and now states:

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 such as codes for …

The guideline also adds:

For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, 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, since this information represents social information, rather than medical diagnoses.

The BMI, coma scale, NIHSS codes and categories Z55-Z65 should only be reported as secondary diagnoses.

Guideline I.B.19 Provides for Hurricane Victims

Guideline I.B.19 Coding for Health Encounters in Hurricane Aftermath is new for 2019. For injuries incurred as a direct result of the hurricane, assign the appropriate code(s) for the injuries, followed by X37.0- Hurricane (with the appropriate seventh character) and any other applicable external cause of injury codes. Per the new guideline, “Codes for cataclysmic events, such as a hurricane, take priority over all other external cause codes except child and adult abuse and terrorism and should be sequenced before other external cause of injury codes.” Under I.B.19.b, sequencing guidelines explain further, “Assign as many external cause of morbidity codes as necessary to fully explain each cause.”

The guidelines specify to never record external cause morbidity codes. as a principal diagnosis (first-listed in non-inpatient settings). Rather, sequence the appropriate injury code before the external cause code(s). The external cause of morbidity codes capture:

• How the injury or health condition happened (cause);
• The intent (unintentional or accidental; or intentional, such as suicide or assault);
• The place where the event occurred;
• The activity of the patient at the time of the event; and
• The person’s status (e.g., civilian, military).

Do not assign external cause of morbidity codes for encounters for treating hurricane victims’ medical conditions when no injury, adverse effect, or poisoning is involved.

The guidelines provide instruction for properly reporting conditions resulting from flooding in a hurricane, and more.

Guideline I.C.1.d.5(b) Expands on Sepsis Coding

Guideline I.C.1.d.5(b) offers new coding advice on sepsis due to a postprocedural infection. For infections following a procedure report first a code from T81.40 – T81.43 Infection following a procedure or a code from O86.00 – O86.03 Infection of obstetric surgical wound to identify the site of the infection, when known. Then, assign an additional code:

• For sepsis following a procedure (T81.44); or
• For sepsis following an obstetrical (OB) procedure (O86.04); and
• To identify the infectious agent.

For infections following infusion, transfusion, therapeutic injection, or immunization, first choose a code from subcategories T80.2 Infections following infusion, transfusion and therapeutic injection or T88.0- Infection following immunization, and then choose a code for the specific infection.

If the patient has severe sepsis, assign an appropriate code from subcategory R65.2 Severe sepsis, with the additional codes(s) for acute organ dysfunction.

Guideline I.C.1.d.5(b) also explains:

If a postprocedural infection has resulted in postprocedural septic shock, assign the codes indicated above for sepsis due to a postprocedural infection, followed by code T81.12-, Postprocedural septic shock. Do not assign code R65.21, Severe sepsis with septic shock. Additional code(s) should be assigned for any acute organ dysfunction.

Guideline I.C.5.c Addresses Factitious Disorders

Guideline I.C.5.c is new for 2019, and it addresses “factitious disorders,” which are disorders imposed on oneself or Munchausen’s syndrome, where a person falsely reports or causes their own physical or psychological signs or symptoms. If a patient is documented to have self-imposed a factitious disorder, or has Munchausen’s syndrome, choose an appropriate code from subcategory F68.1- Factitious disorder imposed on self. Caregivers can also impose factitious disorders on those they care for. In those circumstances, the guideline explains:

Munchausen’s syndrome by proxy (MSBP) is a disorder in which a caregiver (perpetrator) falsely reports or causes an illness or injury in another person (victim) under his or her care, such as a child, an elderly adult, or a person who has a disability. The condition is also referred to as “factitious disorder imposed on another” or “factitious disorder by proxy.” The perpetrator, not the victim, receives this diagnosis. Assign code F68.A, Factitious disorder imposed on another, to the perpetrator’s record. For the victim of a patient suffering from MSBP, assign the appropriate code from categories T74, Adult and child abuse, neglect and other maltreatment, confirmed, or T76, Adult and child abuse, neglect and other maltreatment, suspected.

Guideline I.C.9.a Defines Hypertension

Guidelines for hypertension coding are revised at section I.C.9.a, which now specifies:

1) Hypertension with Heart Disease

Hypertension with heart conditions classified to I50.- or I51.4 – I51.7, I51.89, I51.9, are assigned to a code from category I11, Hypertensive heart disease. Use additional code(s) from category I50, Heart failure, to identify the type(s) of heart failure in those patients with heart failure.

The same heart conditions (I50.-, I51.4 – I51.7, I51.89, I51.9) with hypertension are coded separately if the provider has documented they are unrelated to the hypertension. Sequence according to the circumstances of the admission/encounter.

Guideline I.C.9.a(2) adds the instruction, “CKD should not be coded as hypertensive if the provider indicates the CKD is not related to the hypertension.”

Guideline I.C.9.a(11) adds new language to clarify that when coding associated conditions or adverse effects of drugs or toxins, “The sequencing is based on the reason for the encounter, except for adverse effects of drugs (See Section I.C.19.e.).”

Guideline I.C.9.e(4) Specifies Myocardial Infarction Types

Guideline I.C.9.e(4) adds detail regarding a subsequent myocardial infarction (MI), explaining, “If a subsequent MI of one type occurs within four weeks of a different type, assign the appropriate codes from category I21 to identify each type.” Category I22 codes are only for when both the initial and subsequent MI are type 1 or unspecified, the guidelines newly explain.

The guidelines go on to add I21.9 Acute myocardial infarction, unspecified to the list of codes you may assign to type 1 MI.

Guideline I.C.15.l(3) Instructs Coding for Drug Use During Pregnancy

Guideline I.C.15.l(3) is new for 2019, and specifies that, for any documented case of a mother using drugs during pregnancy or postpartum, you should choose a code under subcategory O99.32 Drug use complicating pregnancy, childbirth, and the puerperium. This includes illegal drugs, or inappropriately using or abusing prescription drugs. Assign the secondary code(s) from categories F11-F16 and F18-F19 to identify drug use manifestations.

Guideline I.C.19.d Burn Coding Adds Site

In 2019, guideline I.C.19.d(2) adds terminology to the burn coding definition:

Burns of the same anatomic site now classify burns of the same anatomic site and on the same side but of different degrees to the subcategory identifying the highest degree recorded in the diagnosis (e.g., for second and third degree burns of right thigh, assign only code T24.311-).

Guideline I.C.19.d(5) now specifies, “Codes for burn of ‘multiple sites’ should only be assigned when the medical record documentation does not specify the individual sites.”

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

Guideline I.C.19.e.5(c) includes terminology changes:

Discontinuing the use of a prescribed medication on the patient’s own initiative (not directed by the patient’s provider) is also classified as an underdosing. The guideline also adds subcategory Z91.14- to the noncompliance of patient medication.

Guideline I.C.19.f Guides You on Reporting Human Trafficking

Guideline I.C.19.f has updated instructions for reporting examination and observation of human trafficking victimization to include suspected forced sexual exploitation or forced labor. When a suspected case of forced sexual exploitation or forced labor exploitation is ruled out during an encounter, use ICD-10-CM code Z04.81 Encounter for examination and observation of victim following forced sexual exploitation or Z04.82 Encounter for examination and observation of victim following forced labor exploitation, not a code from T76 Adult and child abuse, neglect and other maltreatment, suspected.

Guideline I.C.21.c(3) Says Don’t Automatically Report BMI

Guideline I.C.21.c(3) now says, “BMI codes should only be assigned when the associated diagnosis (such as overweight or obesity) meets the definition of a reportable diagnosis. Do not assign BMI codes during pregnancy.” See section I.B.14 for body mass index (BMI) documentation by clinicians other than the patient’s provider.