2023 ICD-10 official guidelines for coding and reporting updates

Q: Can you please provide a summary of the ICD-10-CM Guidelines for 2023?

Fiscal Year (FY) 2023 ICD-10-CM Guidelines take effect October 1, 2022, and reflect the new ICD-10-CM codes as of that date. In the guidelines, the changes are in bold so that the reader can distinguish what is newly added or altered.

Guideline I.A.19, Code assignment and Clinical Criteria

This section has been updated to align more closely with what we have been taught for years.The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists, and their statement is sufficient. The guideline further clarifies that, “If there is conflicting medical record documentation, query the provider.”

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

Underimmunization status was added to the listing of documentation elements that can be coded from non-provider documentation. Specifically, unvaccinated and partially vaccinated (i.e., underimmunized) for COVID-19 can be documented by others and picked up by the coder.

I.B.16, Documentation of Complications of Care

In this section, the addition to the guideline states that the documentation must support that the condition is clinically significant, but the provider does not have to be explicit in calling it “a complication.” Specifically, the guideline reads, “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. It goes on to stipulate, “Query the provider for clarification if the documentation is not clear as to the relationship between the condition and the care or procedure.”The sole responsibility doesn’t rest on the coder; when in doubt, have a discussion with the provider.

I.C.1.a.2), Selection and sequencing of HIV codes

As you know, HIV-related conditions are normally sequenced with B20, Human immunodeficiency virus [HIV] disease, followed by additional diagnosis code(s) or all HIV-related conditions.

The guideline now reads, “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.”This sequencing makes more sense because the patient is being admitted because they have HUS, but there is an HIV backdrop.

I.C.2.a, Admission/Encounter for treatment of primary site

In the Neoplasm chapter, the guidelines clarify that the primary malignancy is sequenced as principal first-listed diagnosis if it is “chiefly responsible for occasioning the patient admission/encounter and treatment is directed at the primary site.” Conversely, if treatment for a malignancy such as chemotherapy, immunotherapy, or radiation therapy is the reason for the admission, the Z51.- code would be principal/first-listed and the malignancy would be a secondary diagnosis. It has always been that way, but the new wording makes it crystal-clear now.

I.C.2.t., Secondary malignant neoplasm of lymphoid tissue

This section was added and clarifies what clinically makes sense, “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.”

Normally, a malignancy that spreads to a secondary site is found in C76-C80, Malignant neoplasms of ill-defined, other secondary and unspecified sites, subcategorized by site, such as lung or bone. If it is carcinoid, there is a separate subcategory of secondary neuroendocrine tumors. However, if a lymphoid cancer (e.g., lymphoma) spreads to a solid organ, the proper code to select has the final character of 9 which indicates extranodal and solid organ sites.

I.C.a., Diabetes mellitus

All the diabetes sections (general and gestational) had a revision clarifying that Z79.84, Long term use of oral hypoglycemic drugs is for use of oral hypoglycemic drugs, not just oral medications as previously indicated. The guidelines are introducing the new code of Z79.85, Long term (current) use of injectable non-insulin antidiabetic drugs to replace the generic other long term drug therapy in appropriate instances.

I.C.5.d., Dementia

Dementia is undergoing a significant expansion indicating severity. The guideline reads, “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.”

This guideline also explains that if a patient is admitted at one severity and progresses, only the higher level is reported.

I.C.15.a.7), Completed weeks of gestation

This includes a new paragraph explaining, “In ICD-10-CM, “completed” weeks of gestation refers to full weeks.” While this seems unnecessary to note, apparently there were some questions regarding this detail.

I.C.15.q.4), Hemorrhage following elective abortion

With the recent Supreme Court ruling regarding abortions, it is more than likely that hemorrhage (and other complications) following an abortion will increase, so this could be an important instruction.It reads, “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.”You either have an uncomplicated encounter or it is complicated; they are mutually exclusive and having a resultant complication, by definition, indicates that you had that procedure.

I.C.19.e.5)(c), Underdosing

This guideline spells out the fact that you don’t need there to be a change in the patient’s condition to assign or capture an underdosing code. If the patient took less than prescribed, even if no adverse effects were experienced, underdosing is still present and clinically significant. If there is a worsening or exacerbation of the condition, that would be another code.

I.C.21.c.10), Counseling

This guideline brings up another new code, Z71.87, Encounter for pediatric-to-adult transition counseling. This can be used as a solo code or can be provided in addition to other conditions such as chronic conditions or another Z encounter code.

I.C.21.c.17), Social Determinants of Health

Finally, for Social Determinants of Health (SDoH), the guidance is that these codes are used only when there are problems arising from the SDoH or if it poses a risk. The example they offer is useful – not every individual living alone should be assigned Z60.2, Problems related to living alone. Another example would be Z56.1, Change of job. This might be a problem causing anxiety or depression warranting recording and coding, or it might be a welcome situation and not be considered an issue. For SDoH to impact medical decision making, the “diagnosis or treatment [needs to be] significantly limited by social determinants of health.”

Resource:Official Guidelines for Coding and Reporting, FY 2023

Renee Dowling is a compliance auditor for Sansum Clinic, LLC, in Santa Barbara, California.