Knowledge Base Article

“The importance 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.”

• Source: ICD-10-CM Official Guidelines for Coding and Reporting FY 2019

The FY 2019 ICD-10-CM Official Guidelines for Coding and Report were recently posted to the Centers for Disease Control and Prevention (CDC) Classification of Diseases, Functioning and Disability webpage.  This article highlights changes to the General Coding and Chapter Specific Guidelines. Narrative changes within the guidelines and this article appear in bold text.

I.B. General Coding Guidelines

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

In the FY 2018 Guidelines, Section 1.B. 14 was titled Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale. As the list of diagnoses has continued to grow from when BMI and Pressure Ulcer Stages guidance first appeared in the 2010 Guidelines, it makes sense to change the section title. For FY 2019 this section is now titled Documentation by Clinicians Other than the Patient’s Provider and begins with the following new sentence:

“Code assignment is based on the documentation by 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...and lists Body Mass Index (BMI), Depth of Non-pressure ulcers, pressure ulcer stages, coma scale and NIH Stroke Scale.

This section also includes new guidance specific to social determinants of health (SDOH). “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.”

You can learn more about Social Determinants of Health in a related MMP article.

I.B. 19. New Section: Coding for Healthcare Encounter in Hurricane Aftermath

Section 1.B.19 is a new and is titled Coding for Healthcare Encounters in Hurricane Aftermath. The subsections in 1.B.19 include:

1. Use of External Cause of Morbidity Codes,
2. Sequencing of External Causes of Morbidity Codes,
3. Other External Causes of Morbidity Code Issues, and
4. Use of Z Codes.

The “Use of Z Codes” section ends with following guidance, “The external cause of morbidity codes and the Z codes listed above are not an all-inclusive list. Other codes may be applicable to the encounter based upon the documentation. Assign as many codes as necessary to fully explain each healthcare encounter. Since patient history information may be very limited, use any available documentation to assign the appropriate external cause of morbidity and Z codes.”

I.C. Chapter-Specific Coding Guidelines

I.C.1. Chapter 1: Certain Infectious and Parasitic Disease (A00-B99)

I.C.1.d. Sepsis Due to a Postprocedural Infection Updated

New guidance has been added to 5(b) Sepsis due to a postprocedural infection and 5(c) Postprocedural infection and postprocedural septic shock.

(b) Sepsis due to postprocedural infection

 “For infections following a procedure, a code from T81.40, to T81.43 Infection following a procedure, or a code from O86.00 to O86.03, Infection of obstetric surgical wound, that identifies the site of the infection should be coded first, if known. Assign an additional code for sepsis following a procedure (T81.44) or sepsis following an obstetrical procedure (O86.04). Use an additional code to identify the infectious agent. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction.

For infections following infusion, transfusion, therapeutic injection, or immunization, a code from subcategory T80.2, Infections following infusion, transfusion, and therapeutic injection, or code T88.0-, Infection following immunization, should be coded first, followed by the code for the specific infection. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned, with the additional code(s) for any acute organ dysfunction.

(c) Postprocedural infection and postprocedural septic shock

If a postprocedural infection has resulted in postprocedural sepsis shock, assign the codes indicated above for sepsis due to postprocedural infection, followed by code Y81.12-, 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.”

I.C.1.f. Zika “Suspected”, “possible” or “probable

FY 2018 guidance for coding “suspected”, “possible” or “probable” Zika virus infections advised to not assign code A92.5 (Zika virus disease). Instead, assign a code(s) explaining the reason for the encounter (such as fever, rash, or joint pain) or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.

For FY 2019, instead of coding Z20.828 you should code Z20.821, Contact with and (suspected) exposure to Zika virus.

I.C. 2.  Chapter 2: Neoplasms (C00-D49)

I.C.2.m. Current malignancy versus personal history of malignancy

New to this section is the following guidance: “Subcategories Z85.0-Z85.7 should only be assigned for the former site of a primary malignancy, not the site of a secondary malignancy. Codes from subcategory Z85.8-, may be assigned for the former site(s) of either a primary or secondary malignancy included in this subcategory.”

I.C. 5 Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01-F99)

5.c. Factitious Disorder

This new section in the FY 2019 Guidelines defines and provides guidance for coding “Factitious disorder imposed on self or Munchausen’s syndrome.”

I.C. 9. Chapter 9: Diseases of the Circulatory System I00-I99)

I.C.9.a.1. Hypertension with Heart Disease

Additional I-10-CM codes classifying hypertension with heart conditions have been added.

I.C.9.a.2. Hypertensive Chronic Kidney Disease

The FY 2018 Guidance included the following statement: “CKD should not be coded as hypertensive if the physician has specifically documented a different cause.” For FY 2019, the guidelines now indicate that “CKD should not be coded as hypertensive if the provider indicates the CKD is not related to the hypertension.”

I.C.9.a.11. Pulmonary Hypertension

Pulmonary Hypertension specific guidance was new in the FY 2018 Guidelines and the guidance ended with the note that “the sequencing is based on the reason for the encounter.” For FY 2019, the following caveat to this guidance has been added, “The sequencing is based on the reason for the encounter, except for adverse effects of drugs (See Section 1.C.19.e.).”

I.C.9.e.4. Subsequent acute myocardial infarction

New to subsequent acute myocardial infarction is the statement, “If a subsequent myocardial infarction of one type occurs within 4 weeks of a myocardial infarction of a different type, assign the appropriate codes from category I21 to identify each type. Do not assign a code I22. Codes from category I22 should only be assigned if both the initial and subsequent myocardial infarction are type 1 or unspecified.”

I.C.15. Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)

I.C.15.l.3. Drug use during pregnancy, childbirth and the puerperium

In FY 2018 this section addressed alcohol and tobacco use during pregnancy, childbirth and the puerperium. A third paragraph has been added to address drug use and directs a coder that “Codes under subcategory O99.32, Drug use complicating pregnancy, childbirth, and the puerperium, should be assigned for any pregnancy case when a mother uses drugs during the pregnancy or postpartum. This can involve illegal drugs, or inappropriate use or abuse of prescription drugs. Secondary code(s) from categories F11-F16 and F18-F19 should also be assigned to identify manifestations of the drug use.”

I.C.18. Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

I.C.18.e. Coma Scale

New guidance at the end of this section indicates you “do not report codes for individual or total Glasgow coma scale scores for a patient with a medically induced coma or a sedated patient.

See Section IB.14 for comas scale documentation by clinicians other than the patient’s provider.”

I.C.19. Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)

I.C.19.d.2. Burns of the same anatomic site

This section has been retitled from Burns of the same local site to Burns of the same anatomic site for FY 2019. Further specificity has been added to this section as follow: Classify burns of the same anatomic site and on the same side but of different degrees to the subcategory identifying the highest degree records in the diagnosis (e.g., for second and third degree burns of right thigh, assign only code T24.311-).

I.C.19.d.5. Assign separate codes for each burn site

“When coding burns, assign separate codes for each burn site. Category T30, Burn and corrosion, body region unspecified is extremely vague and should rarely be used.” A second paragraph has been added to this section instructing that “Codes for burns of “multiple sites” should only be assigned when the medical record documentation does not specify the individual sites.”

I.C.19.e.5.c. Underdosing

“Discontinuing the use of a prescribed medication on the patient’s own initiative (not direct by the patient’s provider is also classified as an underdosing,” expands the Guideline’s definition of underdosing.   

I.C.19.f. Adult and child abuse, neglect and other maltreatment

In addition to guidance about coding abuse, neglect, rape or sexual abuse the following paragraph has been added: “If a suspected case of force sexual exploitation or forced labor exploitation is ruled out during an encounter, code Z04.81, Encounter for examination and observation of victim following forced sexual exploitation, or code Z04.82, Encounter for examination and observation of victim following forced labor exploitation, should be used, not a code from T76.”

I.C.21. Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)

Code Z68 Body Mass Index (BMI)

New to the guidance for coding a patient’s BMI is the following:

• BMI codes should only be assigned when the associated diagnosis (such as overweight or obesity) meets the definition of a reportable diagnosis.
• Do no assign BMI codes during pregnancy, and
• See Section I.B.14 for BMI documentation by clinicians other than the patient’s provider.

This article is meant as an overview, reading the Guidelines is a must for Coding and Clinical Documentation Improvement Professionals as you prepare for changes come October 1, 2018.