Knowledge Base Article

For students,’ summer is quickly winding down and at least for my youngest nephew, he starts back to school on August 9th. More years ago, than I care to share, this time of year was crunch time to finish all my required summer reading before facing a quiz in the first week of English class. Inevitably, there were books that I just knew I would not enjoy, that ended up being my favorite read of the summer.

Now, instead of reading literary classics, my summer reading consists of the coming CY OPPS and Physician Fee Schedule Proposed Rules, the coming FY IPPS Final Rule, and the updated ICD-10-CM Official Guidelines for the new October 1st FY. Today, I offer a “Cliffs Notes®” version of changes in the ICD-10-CM Official Guidelines for FY 2022.

The ICD-10-CM Official Guidelines for FY 2022 were released on Monday, July 12 and can be found on the CDC ICD-10-CM webpage (link) as well as the 2022 ICD-10-CM CMS webpage (link).

Section B2. General Coding Guideline – Level of Detail in Coding

2021 Guidance: Diagnosis codes are to be used and reported at their highest number of characters available.

2022 Guidance: Adds to this sentence “and to the highest level of specificity documented in the medical record.

Section B12. General Coding Guideline – Laterality

The following paragraph has been added to this section. For CDI Professionals, note the guidance includes the possible need for a physician query.

“When laterality is not documented by the patient’s provider, code assignment for the affected side may be based on medical record documentation from other clinicians. If there is conflicting medical record documentation regarding the affected side, the patient’s attending provider should be queried for clarification. Codes for “unspecified” side should rarely be used, such as when the documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification.”

Section B14. General Coding Guideline – Documentation by Clinicians Other than the Patient’s Provider

As a reminder, in 2021 this section was updated to include the following statement regarding the 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.”

New for FY 2022, the guidelines:

• Defines “clinicians,” • Adds “blood alcohol level” to the ever-growing list of code assignment exceptions,” and • Along with BMI, coma scale, and NIHSS, adds blood alcohol level codes and codes for social determinants of health to the list of exception codes that should on be reported as a secondary diagnosis.

Section B18. General Coding Guideline – Use of Signs/Symptom/Unspecified Codes

A new paragraph has been added to this section reminding you that:

• Achieving complete and accurate documentation, code assignment, and reporting of diagnoses and procedures is a joint effort between the healthcare provider and the coder, • Without consistent and complete documentation in the medical record, accurate coding can’t occur, and • The entire record should be reviewed to determine the reason for the encounter and what conditions were being treated.

Section C. Chapter-Specific Coding Guideline – Chapter 1: Certain Infectious and Parasitic Diseases -Coronavirus infections – Section 1g – Coronavirus Infections

This section includes several updates related to coding COVID-19, for example:

• Updated information related to follow-up visits after COVID-19 infection has resolved, and • New information related to Post COVID-19 Condition

Section C. Chapter-Specific Coding Guidelines – Chapter 5: Mental, Behavioral and Neurodevelopment disorders – Section b. 5 – Blood Alcohol Level

Blood Alcohol Level is a new section in Chapter 5 that provides the following guidance related to coding blood alcohol levels: “A code from category Y90, Evidence of alcohol involvement determined by blood alcohol level, may be assigned when this information is documented and the patient’s provider has documented a condition classifiable to category F10, Alcohol related disorders. The blood alcohol level does not need to be documented by the patient’s provider in order for it to be coded.”

Although there are other updates to be found in the FY 2022 Guidelines, as I promised a “Cliffs Notes®” review, I will stop here and encourage you to add this document to your own summer reading list.