Knowledge Base Article

The ICD-10-CM Officials Guidelines “have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are reported. The important of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

The Guidelines for FY 2021 were released at the beginning of July and can be found on the CDC ICD-10-CM webpage as well as the 2021 ICD-10-CM CMS webpage. This article highlights changes to already current sections in the guidelines as well as new sections for EVALI and COVID-19.

Documentation by Clinicians Other than the Patient’s Provider: Social Determinants of Health (SDOH)

Over the past several years this section of the Guidelines has included more and more instances when “code assignment may be based on medical record documentation from clinicians who are not the patient’s provider.” These instances include: Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, NIH stroke scale (NIHSS), and social determinants of health codes found in categories Z55-Z65.

The 2021 Guidelines adds the following statement regarding assignment of social determinant codes:

“Patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider.”

Coding COVID-19

Chapter 1 of the Guidelines, Certain Infectious and Parasitic Diseases, includes a new section for Coronavirus infections. Coders are advised to “code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19) as documented by the provider or documentation of a positive COVID-19 test result. For a confirmed diagnosis, assign code U07.1, COVID-19. This is an exception to the hospital inpatient guideline Section II, H. In this context, “confirmation” does not require documentation of a positive test result for COVID-19; the provider’s documentation that the individual has COVID-19 is sufficient.”

If the provider documents “suspected,” “possible,” “probable,” or “inconclusive” COVID-19, do not assign code U07.1. Instead, code the signs and symptoms reports. See guideline I.C.I.g.I.g.”

This new COVID-19 section also provides guidance for the following coding issues:

• Sequencing of codes,
• Acute respiratory manifestations of COVID-19,
• Non-respiratory manifestations of COVID-19,
• Exposure to COVID-19,
• Screening for COVID-19,
• Signs and Symptoms without definitive diagnosis of COVID-19,
• Asymptomatic individuals who test positive for COVID-19,
• Personal history of COVID-19,
• Follow-up visits after COVID-19 infection has resolved, and
• Encounter for antibody testing.

New coding guidance related to COVID-19 is also included in chapters 15 and 16 (“Pregnancy, Childbirth, and the Puerperium” and “Infection in Newborn, respectively”).

Diabetes Mellitus and the Use of Insulin, Oral Hypoglycemics, and Injectable Non-Insulin Drugs

Lately, it seems like every time I turn on the television there is a commercial for a new “long-acting” drug to treat diabetes. For this reason, it is very timely that the following guidance has been added to the FY 2021 Guidelines:

“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 Z79.899, Other long term (current) drug therapy. 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 Z79.899, Other long-term (current) drug therapy.”

Note, this same guidance has been added to the section Secondary diabetes mellitus and the use of insulin or oral hypoglycemic drugs.

Mental and Behavioral Disorders Due to Psychoactive Substance Use

In the “psychoactive substance use, unspecified,” the guidelines previously advised that “as with all other unspecified diagnoses, the codes for unspecified psychoactive substance use…should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis.”

New for FY 2021, the following bolded guidance has been added:

“These codes are to be used only when the psychoactive substance use is association with a physical disorder included in chapter 5 (such as sexual dysfunction and sleep disorder), or a mental or behavioral disorder, and such a relationship is documented by the provider.”

Hypertensive Heart and Chronic Kidney Disease

FY 2020 Guidance: “If a patient has hypertensive chronic kidney disease and acute renal failure, an additional code for the acute renal failure is required.”

FY 2021 Guidance: “If a patient has hypertensive chronic kidney disease and acute renal failure, the acute renal failure should also be coded. Sequence according to the circumstances of the admission/encounter.”

Vaping-Related Disorders

It is hard to believe that this time last year the CDC, FDA, and state health authorities were diligently working to identify the cause of the national outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI). According to the CDC webpage devoted to this disease, as of February 18, 2020 a total of 2,807 hospitalized EVALI cases or deaths had been reported to the CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands).

Initial vaping coding guidance was released in 2019 and a new ICD-10-CM code was implemented on April 1, 2020. Information about both can be downloaded from the CDC ICD-10-CM webpage at https://www.cdc.gov/nchs/icd/icd10cm.htm.

Specific to the Coding Guidelines, the following has been added for FY 2021:

“For patients presenting with condition(s) related to vaping, assign code U07.0, Vaping-related disorder, as the principal diagnosis. For lung injury due to vaping, assign only code U07.0. Assign additional codes for other manifestations, such as acute respiratory failure (subcategory J96.0-) or pneumonitis (code J68.0).

Associated respiratory signs and symptoms due to vaping, such as cough, shortness of breath, etc., are not coded separately, when a definitive diagnosis has been established. However, it would be appropriate to code separately any gastrointestinal symptoms, such as diarrhea and abdominal pain.”

Puerperal Sepsis

For FY 2021, the guidelines advise that “Code O85 should not be assigned for sepsis following an obstetrical procedure (See Section I.C.1.d.5.b., Sepsis due to a postprocedural infection).”

Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00-Z99) – Observation

The three observation z code categories “are for use in very limited circumstances when a person is being observed for a suspected condition that is ruled out. The observation codes are not for use if an injury or illness or any signs or symptoms related to the suspected condition are present. In such cases the diagnosis/symptom code is used with the corresponding external code cause.”

FY 2020 Guidance: “The observation codes are to be used as principal diagnosis only. The only exception to this is when the principal diagnosis is required to be a code from category Z38, Liveborn infants according to place of birth and type of delivery.”

FY 2021 Guidance: “The observation codes are primarily to be used as a principal/first-listed diagnosis. An observation code may be assigned as a secondary diagnosis code when the patient is being observed for a condition that is ruled out and is unrelated to the principal/first-listed diagnosis (e.g., patient presents for treatment following injuries sustained in a motor vehicle accident and is also observed for suspected COVID-19 infection that is subsequently ruled out).”

Chapter 22: Codes for Special Purposes (U00-U85) NEW

This new chapter for FY 2021 includes the Vaping-related disorder code, U07.0 and COVID-19 code, U07.1. The reader is referenced back to prior sections in the Guidelines for guidance on coding both of these conditions.

While I have highlighted updates for FY 2021, I believe the Guidelines are an essential annual read for Coding and Clinical Documentation Integrity (CDI) Professionals. As I think of school systems struggling with the decision of whether to and when to reopen schools, you can consider reading the FY 2021 Coding Guidelines your required summer reading for the coming Fiscal Year.