Medical group leaders know that proper documentation and coding is a keystone to overall revenue cycle management for practices.
Each year, it becomes important to be ready for code adjustments that become active in October and at the start of the new year. For example, the ICD-10 Coordination and Maintenance Committee met Sept. 11 and 12, 2018, to review current codes to modify, change or add. Those coding adjustments were published and were active as of Oct. 1, 2019, and they remain active through Sept. 30, 2020.
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ICD-10-CM guideline changes for 2020 are easy to identify as they are bolded in the book and most e-books. There are many items that have been moved which is indicated by underlining. You’ll also notice italicized font which indicate revisions to headings.
ICD-10-CM guidelines begin with the change of term provider from physician and is defined as: provider means a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis. This is bolded throughout the entirety of the guidelines.
Section I, Chapter 2, d. Primary Neoplasm Previously Excised, added the word diagnosis in the last sentence.
Section I, Chapter 9, e. Acute myocardial infarction, 5) Other Types of Myocardial Infarction, notice bolded items in the second paragraph advising to code first MI type 2 with underlying cause. Also note “If” was added to the last sentence. This change is made to simplify understanding on how to code type 2 MI as described as STEMI or non-STEMI.
Section I, Chapter 12, a. Pressure ulcer stages, 7) Pressure-induced deep tissue damage, added an important note on coding deep tissue code assignment for pressure-induced deep tissue damage or deep tissue pressure injury, assign only the appropriate code for pressure-induced deep tissue damage (L89.--6).
Section I, Chapter 12, a. Pressure ulcer stages, 4) Patients admitted with pressure ulcers documented as healed, an important note was added stating “at the time of admission”. The guideline specifically states not to assign the code if the documentation states pressure ulcer is completely healed at the time of admission.
Section I, Chapter 15, n. Normal Deliver, Code O80, 1) Encounter for full term uncomplicated delivery, the term “postnatal” was added. This was changed from “perinatal” to “postnatal”.
Section I, Chapter 19, b. Coding of Injuries, 3) Iatrogenic Injuries, added an important note on coding these injuries as complications. Injury codes from Chapter 19 should not be assigned for injuries that occur during, or as a result of, a medical intervention. Assign the appropriate complication code(s).
Section I, Chapter 19, c. Coding of Traumatic Fractures, 3) Physeal Fractures, added important dialect on guidance for physeal fractures, assign only the code identifying the type of physeal fracture. Do not assign a separate code to identify the specific bone that is fractured.
Section I, Chapter 19, e. Adverse, Effects, Poisoning, Underdosing and Toxic Effects, 4) If two or more drugs, medicinal or biological substances, added the word taken. If multiple unspecified drugs, medicinal or biological substances were taken, assign the appropriate code from subcategory T50.91, Poisoning by, adverse effect of and underdosing of multiple unspecified drugs, medicaments and biological substances.
Section I, Chapter 19 , g. Complications of care, 5) Complications of care codes within the body system chapters, updated notes related to T50.91 subcategory identifying complication codes from the body system chapters should be assigned for intraoperative and postprocedural complications (e.g., the appropriate complication code from chapter 9 would be assigned for a vascular intraoperative or postprocedural complication) unless the complication is specifically indexed to a T code in chapter 19.
Section I, Chapter 21, c. Categories of Z Codes, 3) Status, added some content on BMI code Z68 Body mass index (BMI) BMI codes should only be assigned when there is an associated, reportable diagnosis (such as obesity). Do not assign BMI codes during pregnancy.
Section I, Chapter 21, c. Categories of Z Codes, 10) Counseling, added a note: Code Z71.84, Encounter for health counseling related to travel, is to be used for health risk and safety counseling for future travel purposes.
Section II, H. Uncertain Diagnosis, added verbiage “compatible with,” “consistent with,” to terms of uncertainty.
Section III, C. Uncertain Diagnosis, added “compatible with,” “consistent with,” to terms of uncertainty.
Section IV, H. Uncertain Diagnosis, added “compatible with,” “consistent with,” to terms of uncertainty.
Each year, it becomes important to be ready for code adjustments that become active in October and at the start of the new year. For example, the ICD-10 Coordination and Maintenance Committee met Sept. 11 and 12, 2018, to review current codes to modify, change or add. Those coding adjustments were published and were active as of Oct. 1, 2019, and they remain active through Sept. 30, 2020.
ICD-10-CM codes
There are 273 new codes under ICD-10-CM, used to code and classify morbidity and mortality:{^widget|(widget_displayname)Accordion+Item|(accordionitemheader)Chapter+3+%5bDiseases+of+the+Blood+and+Blood-forming+Organs+and+Certain+Disorders+Involving+the+Immune+Mechanism+(D50-D89)%5d+%e2%80%94+5+new+codes|(name)AccordionItem|(accordionitemcontent)%3cul%3e%0d%0a%09%3cli%3eD75.A+Glucose-6-phosphate+dehydrogenase+(G6PD)+deficiency+without+anemia%3c%2fli%3e%0d%0a%09%3cli%3eD81.30+Adenosine+deaminase+deficiency%2c+unspecified%3c%2fli%3e%0d%0a%09%3cli%3eD81.31+Severe+combined+immunodeficiency+due+to+adenosine+deaminase+deficiency%3c%2fli%3e%0d%0a%09%3cli%3eD81.32+Adenosine+deaminase+2+deficiency%3c%2fli%3e%0d%0a%09%3cli%3eD81.39+Other+adenosine+deaminase+deficiency%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a|(width)|(height)^}
{^widget|(widget_displayname)Accordion+Item|(accordionitemheader)Chapter+8+%5bDiseases+of+the+Ear+and+Mastoid+Process+(H60-H95)%5d+%e2%80%94+1+new+code|(name)AccordionItem|(accordionitemcontent)%3cul%3e%0d%0a%09%3cli%3eH81.4+Vertigo+of+central+origin%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a|(width)|(height)^}
{^widget|(widget_displayname)Accordion+Item|(accordionitemheader)Chapter+9+%5bDiseases+of+the+Circulatory+System+(I00-I99)%5d+%e2%80%94+30+new+codes|(name)AccordionItem|(accordionitemcontent)New+codes+added+to+subcategory+I26.9+to+quantify+embolism+without+acute+cor+pulmonale%3a%0d%0a%3cul%3e%0d%0a%09%3cli%3eI26.93+Single+subsegmental+pulmonary+embolism+without+acute+cor+pulmonale%3c%2fli%3e%0d%0a%09%3cli%3eI26.94+Multiple+subsegmental+pulmonary+emboli+without+acute+cor+pulmonale%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0aAtrial+fibrillation+is+a+common+abnormality+of+irregular+heartbeat%2c+but+the+American+College+of+Cardiology+found+that+the+codes+were+not+specific+and+lacked+clinical+integrity.+This+prompted+new+codes%3a%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eI48.11+Longstanding+persistent+atrial+fibrillation%3c%2fli%3e%0d%0a%09%3cli%3eI48.19+Other+persistent+atrial+fibrillation%3c%2fli%3e%0d%0a%09%3cli%3eI48.20+Chronic+atrial+fibrillation%2c+unspecified%3c%2fli%3e%0d%0a%09%3cli%3eI48.21+Permanent+atrial+fibrillation%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0aNew+codes+added+to+subcategory+I80.2+to+identify+phlebitis+and+thrombophlebitis+of+the+peroneal+and+calf+muscle+vein%3a%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eI80.214+Phlebitis+and+thrombophlebitis+of+the+right+peroneal+vein%3c%2fli%3e%0d%0a%09%3cli%3eI80.242+Phlebitis+and+thrombophlebitis+of+the+left+peroneal+vein%3c%2fli%3e%0d%0a%09%3cli%3eI80.243+Phlebitis+and+thrombophlebitis+of+the+peroneal+vein%2c+bilateral%3c%2fli%3e%0d%0a%09%3cli%3eI80.249+Phlebitis+and+thrombophlebitis+of+unspecified+peroneal+vein%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eI80.251+Phlebitis+and+thrombophlebitis+of+right+calf+muscular+vein%3c%2fli%3e%0d%0a%09%3cli%3eI80.252+Phlebitis+and+thrombophlebitis+of+left+calf+muscular+vein%3c%2fli%3e%0d%0a%09%3cli%3eI80.253+Phlebitis+and+thrombophlebitis+of+calf+muscular+vein%2c+bilateral%3c%2fli%3e%0d%0a%09%3cli%3eI80.259+Phlebitis+and+thrombophlebitis+of+unspecified+calf+muscular+vein%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0aNew+codes+added+to+subcategory+I82+to+identify+acute+and+chronic+embolism+and+thrombosis+of+lower+extremity+veins%3a%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eI82.451%26nbsp%3b+Acute+embolism+and+thrombosis+of+right+peroneal+vein%3c%2fli%3e%0d%0a%09%3cli%3eI82.452+Acute+embolism+and+thrombosis+of+left+peroneal+vein%3c%2fli%3e%0d%0a%09%3cli%3eI82.453+Acute+embolism+and+thrombosis+of+peroneal+vein%2c+bilateral%3c%2fli%3e%0d%0a%09%3cli%3eI82.459+Acute+embolism+and+thrombosis+of+unspecified+peroneal+vein%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eI82.461+Acute+embolism+and+thrombosis+of+right+calf+muscular+vein%3c%2fli%3e%0d%0a%09%3cli%3eI82.462+Acute+embolism+and+thrombosis+of+left+calf+muscular+vein%3c%2fli%3e%0d%0a%09%3cli%3eI82.463+Acute+embolism+and+thrombosis+of+calf+muscular+vein%2c+bilateral%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eI82.551+Chronic+embolism+and+thrombosis+of+right+peroneal+vein%3c%2fli%3e%0d%0a%09%3cli%3eI82.552+Chronic+embolism+and+thrombosis+of+left+peroneal+vein%3c%2fli%3e%0d%0a%09%3cli%3eI82.553+Chronic+embolism+and+thrombosis+of+peroneal+vein%2c+bilateral%3c%2fli%3e%0d%0a%09%3cli%3eI82.559+Chronic+embolism+and+thrombosis+of+unspecified+peroneal+vein%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eI82.561+Chronic+embolism+and+thrombosis+of+right+calf+muscular+vein%3c%2fli%3e%0d%0a%09%3cli%3eI82.562+Chronic+embolism+and+thrombosis+of+left+calf+muscular+vein%3c%2fli%3e%0d%0a%09%3cli%3eI82.563+Chronic+embolism+and+thrombosis+of+calf+muscular+vein%2c+bilateral%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0aNew+codes+added+to+subcategory+I26.9+to+quantify+embolism+without+acute+cor+pulmonale%3a%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eI26.93+Single+subsegmental+pulmonary+embolism+without+acute+cor+pulmonale%3c%2fli%3e%0d%0a%09%3cli%3eI26.94+Multiple+subsegmental+pulmonary+emboli+without+acute+cor+pulmonale%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a|(width)|(height)^}
{^widget|(widget_displayname)Accordion+Item|(accordionitemheader)Chapter+12+%5bDiseases+of+the+Skin+and+Subcutaneous+Tissue+(L00-L99)%5d+%e2%80%94+25+new+codes|(name)AccordionItem|(accordionitemcontent)%3cul%3e%0d%0a%09%3cli%3eL89.006+Pressure-induced+deep+tissue+damage+of+unspecified+elbow%3c%2fli%3e%0d%0a%09%3cli%3eL89.016+Pressure-induced+deep+tissue+damage+of+right+elbow%3c%2fli%3e%0d%0a%09%3cli%3eL89.026+Pressure-induced+deep+tissue+damage+of+left+elbow%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eL89.106+Pressure-induced+deep+tissue+damage+of+unspecified+part+of+back%3c%2fli%3e%0d%0a%09%3cli%3eL89.116+Pressure-induced+deep+tissue+damage+of+right+upper+back%3c%2fli%3e%0d%0a%09%3cli%3eL89.126+Pressure-induced+deep+tissue+damage+of+left+upper+back%3c%2fli%3e%0d%0a%09%3cli%3eL89.136+Pressure-induced+deep+tissue+damage+of+right+lower+back%3c%2fli%3e%0d%0a%09%3cli%3eL89.146+Pressure-induced+deep+tissue+damage+of+left+lower+back%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eL89.156+Pressure-induced+deep+tissue+damage+of+sacral+region%3c%2fli%3e%0d%0a%09%3cli%3eL89.206+Pressure-induced+deep+tissue+damage+of+unspecified+hip%3c%2fli%3e%0d%0a%09%3cli%3eL89.216+Pressure-induced+deep+tissue+damage+of+right+hip%3c%2fli%3e%0d%0a%09%3cli%3eL89.226+Pressure-induced+deep+tissue+damage+of+left+hip%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eL89.306+Pressure-induced+deep+tissue+damage+of+unspecified+buttock%3c%2fli%3e%0d%0a%09%3cli%3eL89.316+Pressure-induced+deep+tissue+damage+of+right+buttock%3c%2fli%3e%0d%0a%09%3cli%3eL89.326+Pressure-induced+deep+tissue+damage+of+left+buttock%3c%2fli%3e%0d%0a%09%3cli%3eL89.46+Pressure-induced+deep+tissue+damage+of+contiguous+site+of+back%2c+buttock+and+hip%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eL89.506+Pressure-induced+deep+tissue+damage+of+unspecified+ankle%3c%2fli%3e%0d%0a%09%3cli%3eL89.516+Pressure-induced+deep+tissue+damage+of+right+ankle%3c%2fli%3e%0d%0a%09%3cli%3eL89.526+Pressure-induced+deep+tissue+damage+of+left+ankle%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eL89.606+Pressure-induced+deep+tissue+damage+of+unspecified+heel%3c%2fli%3e%0d%0a%09%3cli%3eL89.616+Pressure-induced+deep+tissue+damage+of+right+heel%3c%2fli%3e%0d%0a%09%3cli%3eL89.626+Pressure-induced+deep+tissue+damage+of+left+heel%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eL89.816+Pressure-induced+deep+tissue+damage+of+head%3c%2fli%3e%0d%0a%09%3cli%3eL89.896+Pressure-induced+deep+tissue+damage+of+other+site%3c%2fli%3e%0d%0a%09%3cli%3eL89.96+Pressure-induced+deep+tissue+damage+of+unspecified+site%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a|(width)|(height)^}
{^widget|(widget_displayname)Accordion+Item|(accordionitemheader)Chapter+14+%5bDiseases+of+the+Genitourinary+System+(N00-N99)%5d+%e2%80%94+3+new+codes|(name)AccordionItem|(accordionitemcontent)%3cul%3e%0d%0a%09%3cli%3eN63.15+Unspecified+lump+in+the+right+breast%2c+overlapping+quadrants%3c%2fli%3e%0d%0a%09%3cli%3eN63.25+Unspecified+lump+in+the+left+breast%2c+overlapping+quadrants%3c%2fli%3e%0d%0a%09%3cli%3eN99.85+Post+endometrial+ablation+syndrome%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a|(width)|(height)^}
{^widget|(widget_displayname)Accordion+Item|(accordionitemheader)Chapter+17+%5bCongenital+Malformations%2c+Deformations+and+Chromosomal+Abnormalities+(Q00-Q99)%5d+%e2%80%94+31+new+codes|(name)AccordionItem|(accordionitemcontent)New+codes+have+been+added+to+identify+laterality.%0d%0a%3cul%3e%0d%0a%09%3cli%3eQ66.00+Congenital+talipes+equinovarus%2c+unspecified+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.01+Congenital+talipes+equinovarus%2c+right+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.02+Congenital+talipes+equinovarus%2c+left+foot%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eQ66.10+Congenital+talipes+calcaneovarus%2c+unspecified+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.11+Congenital+talipes+calcaneovarus%2c+right+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.12+Congenital+talipes+calcaneovarus%2c+left+foot%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eQ66.211+Congenital+metatarsus+primus+varus%2c+right+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.212+Congenital+metatarsus+primus+varus%2c+left+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.219+Congenital+metatarsus+primus+varus%2c+unspecified+foot%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eQ66.221+Congenital+metatarsus+adductus%2c+right+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.222+Congenital+metatarsus+adductus%2c+left+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.229+Congenital+metatarsus+adductus%2c+unspecified+foot%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eQ66.30+Other+congenital+varus+deformities+of+feet%2c+unspecified+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.31+Other+congenital+varus+deformities+of+feet%2c+right+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.32+Other+congenital+varus+deformities+of+feet%2c+left+foot%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eQ66.40+Congenital+talipes+calcaneovalgus%2c+unspecified+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.41+Congenital+talipes+calcaneovalgus%2c+right+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.42+Congenital+talipes+calcaneovalgus%2c+left+foot%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eQ66.70+Congenital+pes+cavus%2c+unspecified+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.71+Congenital+pes+cavus%2c+right+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.72+Congenital+pes+cavus%2c+left+foot%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eQ66.90+Congenital+deformity+of+feet%2c+unspecified%2c+unspecified+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.91+Congenital+deformity+of+feet%2c+unspecified%2c+right+foot%3c%2fli%3e%0d%0a%09%3cli%3eQ66.92+Congenital+deformity+of+feet%2c+unspecified%2c+left+foot%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eQ79.60+Ehlers-Danlos+syndrome%2c+unspecified%3c%2fli%3e%0d%0a%09%3cli%3eQ79.61+Classical+Ehlers-Danlos+syndrome%3c%2fli%3e%0d%0a%09%3cli%3eQ79.62+Hypermobile+Ehlers-Danlos+syndrome%3c%2fli%3e%0d%0a%09%3cli%3eQ79.63+Vascular+Ehlers-Danlos+syndrome%3c%2fli%3e%0d%0a%09%3cli%3eQ79.69+Other+Ehlers-Danlos+syndromes%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a%26nbsp%3b%0d%0a%0d%0a%3cul%3e%0d%0a%09%3cli%3eQ87.11+Prader-Willi+syndrome%3c%2fli%3e%0d%0a%09%3cli%3eQ87.19+Other+congenital+malformation+syndromes+predominantly+associated+with+short+stature%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a|(width)|(height)^}
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Deleted ICD-10- CM codes
A total of 22 codes were deleted in 2020. Many have been replaced with a higher level of specificity.{^widget|(widget_displayname)Accordion+Item|(accordionitemheader)Chapter+3%3a+Diseases+of+the+Blood+and+Blood-forming+Organs+and+Certain+Disorders+Involving+the+Immune+Mechanism|(name)AccordionItem|(accordionitemcontent)%3cul%3e%0d%0a%09%3cli%3eD81.3%26nbsp%3bAdenosine+deaminase+%5bADA%5d+deficiency%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a|(width)|(height)^}
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{^widget|(widget_displayname)Accordion+Item|(accordionitemheader)Chapter+17%3a+Congenital+Malformations%2c+Deformations+and+Chromosomal+Abnormalities|(name)AccordionItem|(accordionitemcontent)%3cul%3e%0d%0a%09%3cli%3eQ66.0%26nbsp%3bCongenital+talipes+equinovarus%3c%2fli%3e%0d%0a%09%3cli%3eQ66.1%26nbsp%3bCongenital+talipes+calcaneovarus%3c%2fli%3e%0d%0a%09%3cli%3eQ66.21%26nbsp%3bCongenital+metatarsus+primus+varus%3c%2fli%3e%0d%0a%09%3cli%3eQ66.22%26nbsp%3bCongenital+metatarsus+adductus%3c%2fli%3e%0d%0a%09%3cli%3eQ66.3%26nbsp%3bOther+congenital+varus+deformities+of+feet%3c%2fli%3e%0d%0a%09%3cli%3eQ66.4%26nbsp%3bCongenital+talipes+calcaneovalgus%3c%2fli%3e%0d%0a%09%3cli%3eQ66.7%26nbsp%3bCongenital+pes+cavus%3c%2fli%3e%0d%0a%09%3cli%3eQ66.9%26nbsp%3bCongenital+deformity+of+feet%2c+unspecified%3c%2fli%3e%0d%0a%09%3cli%3eQ79.6%26nbsp%3bEhlers-Danlos+syndrome%3c%2fli%3e%0d%0a%09%3cli%3eQ87.1%26nbsp%3bCongenital+malformation+syndromes+predominantly+associated+with+short+stature%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a|(width)|(height)^}
{^widget|(widget_displayname)Accordion+Item|(accordionitemheader)Chapter+18%3a+Symptoms%2c+Signs+and+Abnormal+Clinical+and+Laboratory+Findings%2c+not+elsewhere+classified|(name)AccordionItem|(accordionitemcontent)%3cul%3e%0d%0a%09%3cli%3eR82.8%26nbsp%3bAbnormal+findings+on+cytological+and+histological+examination+of+urine%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a|(width)|(height)^}
{^widget|(widget_displayname)Accordion+Item|(accordionitemheader)Chapter+19%3a+Injury%2c+Poisoning+and+Certain+Other+Consequences+of+External+Causes|(name)AccordionItem|(accordionitemcontent)%3cul%3e%0d%0a%09%3cli%3eT67.0XXA%26nbsp%3bHeatstroke+and+sunstroke%2c+initial+encounter%3c%2fli%3e%0d%0a%09%3cli%3eT67.0XXD%26nbsp%3bHeatstroke+and+sunstroke%2c+subsequent+encounter%3c%2fli%3e%0d%0a%09%3cli%3eT67.0XXS%26nbsp%3bHeatstroke+and+sunstroke%2c+sequela%3c%2fli%3e%0d%0a%3c%2ful%3e%0d%0a|(width)|(height)^}
ICD-10-CM guideline updates:
Now that we’ve reviewed ICD-10-CM added and deleted codes, let’s review guideline updates.ICD-10-CM guideline changes for 2020 are easy to identify as they are bolded in the book and most e-books. There are many items that have been moved which is indicated by underlining. You’ll also notice italicized font which indicate revisions to headings.
ICD-10-CM guidelines begin with the change of term provider from physician and is defined as: provider means a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis. This is bolded throughout the entirety of the guidelines.
Section I, Chapter 2, d. Primary Neoplasm Previously Excised, added the word diagnosis in the last sentence.
Section I, Chapter 9, e. Acute myocardial infarction, 5) Other Types of Myocardial Infarction, notice bolded items in the second paragraph advising to code first MI type 2 with underlying cause. Also note “If” was added to the last sentence. This change is made to simplify understanding on how to code type 2 MI as described as STEMI or non-STEMI.
Section I, Chapter 12, a. Pressure ulcer stages, 7) Pressure-induced deep tissue damage, added an important note on coding deep tissue code assignment for pressure-induced deep tissue damage or deep tissue pressure injury, assign only the appropriate code for pressure-induced deep tissue damage (L89.--6).
Section I, Chapter 12, a. Pressure ulcer stages, 4) Patients admitted with pressure ulcers documented as healed, an important note was added stating “at the time of admission”. The guideline specifically states not to assign the code if the documentation states pressure ulcer is completely healed at the time of admission.
Section I, Chapter 15, n. Normal Deliver, Code O80, 1) Encounter for full term uncomplicated delivery, the term “postnatal” was added. This was changed from “perinatal” to “postnatal”.
Section I, Chapter 19, b. Coding of Injuries, 3) Iatrogenic Injuries, added an important note on coding these injuries as complications. Injury codes from Chapter 19 should not be assigned for injuries that occur during, or as a result of, a medical intervention. Assign the appropriate complication code(s).
Section I, Chapter 19, c. Coding of Traumatic Fractures, 3) Physeal Fractures, added important dialect on guidance for physeal fractures, assign only the code identifying the type of physeal fracture. Do not assign a separate code to identify the specific bone that is fractured.
Section I, Chapter 19, e. Adverse, Effects, Poisoning, Underdosing and Toxic Effects, 4) If two or more drugs, medicinal or biological substances, added the word taken. If multiple unspecified drugs, medicinal or biological substances were taken, assign the appropriate code from subcategory T50.91, Poisoning by, adverse effect of and underdosing of multiple unspecified drugs, medicaments and biological substances.
Section I, Chapter 19 , g. Complications of care, 5) Complications of care codes within the body system chapters, updated notes related to T50.91 subcategory identifying complication codes from the body system chapters should be assigned for intraoperative and postprocedural complications (e.g., the appropriate complication code from chapter 9 would be assigned for a vascular intraoperative or postprocedural complication) unless the complication is specifically indexed to a T code in chapter 19.
Section I, Chapter 21, c. Categories of Z Codes, 3) Status, added some content on BMI code Z68 Body mass index (BMI) BMI codes should only be assigned when there is an associated, reportable diagnosis (such as obesity). Do not assign BMI codes during pregnancy.
Section I, Chapter 21, c. Categories of Z Codes, 10) Counseling, added a note: Code Z71.84, Encounter for health counseling related to travel, is to be used for health risk and safety counseling for future travel purposes.
Section II, H. Uncertain Diagnosis, added verbiage “compatible with,” “consistent with,” to terms of uncertainty.
Section III, C. Uncertain Diagnosis, added “compatible with,” “consistent with,” to terms of uncertainty.
Section IV, H. Uncertain Diagnosis, added “compatible with,” “consistent with,” to terms of uncertainty.
Critical reflections:
- Many revisions have been made to descriptions of codes to include verbiage recounting specificity.
- Review all notes, as many have been revised, added and deleted:
- Excludes 1 and 2
- Code first
- Use Additional
- Note
- Code also
- Pay attention to added codes and the diseases that are classified with the code as listed under the main term.
References:
- National Center for Health Statistics. “ICD-10-CM Official Guidelines for Coding and Reporting FY 2020.” Centers for Disease Control and Prevention. Available from: https://www.cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf.
- Centers for Medicare & Medicaid Services. “2020 ICD-10-CM.” Available from: https://www.cms.gov/Medicare/Coding/ICD10/2020-ICD-10-CM.html.
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