Official Coding Guidelines released for Financial Year 2023

Its that time of year! Summer is winding down and we are preparing for the October 1 coding changes. The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) released the Official Coding Guidelines for Coding and Reporting which will be effective starting on October 1, 2022.

Section I was the only part of the guidelines that were revised, Sections II, III, IV, and Appendix I remain unchanged. Following is a summary of changes made to Section I guidelines: Code Assignment and Clinical Criteria (Section I.A.19) ----- This guideline specifies that codes are assigned based on a provider's diagnostic statement and that codes cannot be assigned based on clinical criteria alone. For 2023, the following statement was added "If there is conflicting medical record documentation, query the provider".

Documentation by Clinicians Other than the Patient's Provider (Section I.B.14) - Underimmunization status is now added to the list of diagnosis codes that can be assigned based on documentation by non-physicians. A statement was also added to clarify that underimmunization status can only be a secondary diagnosis.

Documentation of Complications of Care (Section I.B.16) - This guideline used to state that there must be documentation that a condition is a complication:

"There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that is a complication". For 2023, the guideline has been updated to clarify that the provider does not need to specifically document the word "complication".

This updated guideline will satisfy many coders who sometimes fret over the use of complication codes. The new guidelines states: "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". Also added is the statement to query "if the documentation is not clear as to the relationship between the condition and the care or procedure".

Hemolytic-uremic Syndrome (involves multiple sections)

In the following two guidelines, coders are instructed to sequence hemolytic-uremic syndrome as principal diagnosis when present in septic and HIV patients. These are probably the most surprising changes to the guidelines for 2023:

Patient admitted for HIV-related condition (Section I.C.1.a.2.a) - "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".

Hemolytic-uremic syndrome associated with sepsis (Section I.C.1.d.9) - "If the reason for admission is hemolytic-uremic syndrome that is associated with sepsis, assign code D59.31-infection-associated hemolytic-uremic syndrome, as the principal diagnosis. Codes for the underlying systemic infection and any other conditions (such as severe sepsis) should be assigned as secondary diagnoses".

HIV managed by antiretroviral medication (Section I.C.1.1.2.i) - This updated guideline expands the term "HIV disease" to also include "HIV-related illness” and "AIDS" to instruct coders to code B20 for patients on antiretroviral medications.

Admission/Encounter for treatment of primary site (Section I.C.2.a) - This guideline verbiage was expanded to specifically include encounters and first-listed diagnoses to include the outpatient arena. A statement was also added to specify that the malignancy should be the reason for admission/encounter. Here is the new guideline with changes bolded:

"If the malignancy is chiefly responsible for occasioning the patient admission/encounter and treatment is directed at the primary site, designate the primary malignancy as the principal/first-listed diagnosis".

This guideline also included some adjustments to clarify the use of Z51 codes used as principal/first-listed codes. The statement added clarifies that if the administration of chemo/immuno/radiation therapies is chiefly responsible for occasioning the admission/encounter, assign a code from the Z51 category.

Secondary malignant neoplasm of lymphoid tissue (Section I.C.2.t) - This is a new guideline that will provide some solace to coders who have always wondered how to code lymphatic cancers that have metastasized. The new guideline clarifies that "extranodal and solid organ sites" should be used when a lymphoid cancer has metastasized outside of the lymph glands. Z codes for Long Term Anti-diabetic Drug Therapy (involves multiple sections) There were changes to multiple guidelines that specify how to apply codes for long term use of anti-diabetic drugs. The guidelines for diabetes, secondary diabetes and diabetes in pregnancy were all updated to clarify the following:

"If the patient is treated with both oral hypoglycemic drugs and insulin, both code Z79.4, Long term (current) use of insulin, and code Z79.84, Long term (current) use of oral hypoglycemic drugs, should be assigned".

"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 Z79.85, Long-term (current) use of injectable non-insulin antidiabetic drugs".

"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 Z79.85, Long-term (current) use of injectable non-insulin antidiabetic drugs".

Mental and behavioral disorders due to psychoactive substance use In Remission (Section I.C.5.b) - The word "describing" was added to this guideline to specify that words "describing" remission can be used to assign codes for this condition. Numbers .91 were added to the code categories F10-F19.

Dementia (Section I.C.5.d) - There is a new guideline for dementia which help to clarify how to code the severity of dementia. This is the new guideline:

"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. If a patient is admitted to an inpatient acute care hospital or other inpatient facility setting with dementia at one severity level and it progresses to a higher severity level, assign one code for the highest severity level reported during the stay."

Completed weeks of gestation (Section I.C.15.a.7) - This is a new guideline that helps to clarify how to apply the gestational week codes and that weeks must be completed in order to apply the code. For example, if the provider documents gestation at 39 weeks and 6 days, the code for 39 weeks of gestation should be assigned, as the patient has not yet reached 40 completed weeks.

Hemorrhage following elective abortion (Section I.C.15.q.4) - This is a new guideline that guides the coder on how to code hemorrhages following an elective abortion. Postpartum hemorrhage should not be used and the Z code, Z33.2 – encounter for elective termination of pregnancy should not be used when there is a complication, such as hemorrhage. Use of Z05 codes (Section I.C.16.b.1) The word "disease" was added to this guideline in a few places to bolster the word "condition" in using these codes for reporting observation of suspected conditions. A statement was also added to this guideline to clarify that a code from category Z05 should not be used if the patient has signs or symptoms.

Underdosing (Section I.C.19.3.5.c) - The following statement was added to this guideline to help clarify when to use underdosing codes:

"Documentation of a change in the patient’s condition is not required in order to assign an underdosing code. Documentation that the patient is taking less of a medication than is prescribed or discontinued the prescribed medication is sufficient for code assignment". Counseling – (Section I.C.21.c.10) – The following statement was added to this guideline to clarify the use of code Z71.87 for pediatric-to-adult transition counseling.:

"Code Z71.87, Encounter for pediatric-to-adult transition counseling, should be assigned when pediatric-to-adult transition counseling is the sole reason for the encounter or when this counseling is provided in addition to other services, such as treatment of a chronic condition. If both transition counseling and treatment of a medical condition are provided during the same encounter, the code(s) for the medical condition(s) treated and code Z71.87 should be assigned, with sequencing depending on the circumstances of the encounter:.

Miscellaneous Z Codes (Section I.C.21.c.14) A note was added to code Z73 for life management difficulties:

"Note: These codes should be assigned only when the documentation specifies that the patient has an associated problem."

Social Determinants of Health – (Section I.C.21.c.17) - This guideline was updated to updated with terms "problems or risk factors related to" social determinants of health (SDOH). The following statement was also added:

"Assign as many SDOH codes as are necessary to describe all of the problems or risk factors. These codes should be assigned only when the documentation specifies that the patient has an associated problem or risk factor. For example, not every individual living alone would be assigned code Z60.2, Problems related to living alone".

Keep in mind these are the changes going into effect as of October 1, 2022. They are not as sweeping as past years but still have some significance an may affect your daily work. Happy fall and happy coding!