2022 ICD 10 CM Coding Guidelines changes

As we know that we will be having a new updated ICD 10 coding guidelines effective 1st October 2021 and which will be active till next year 2022. So, it is very important to know about the new changes in ICD 10 codes in the latest coding guidelines. Below I have shared  some of the changes (in BOLD letters) in the 2022 ICD10 coding books. 

Level of Detail in Coding

Diagnosis codes are to be used and reported at their highest number of characters
available and to the highest level of specificity documented in the medical record.

Code or codes from A00.0 through T88.9, Z00-Z99.8, U00-U85

The appropriate code or codes from A00.0 through T88.9, Z00-Z99.8, and U00-U85
must be used to identify diagnoses, symptoms, conditions, problems, complaints or
other reason(s) for the encounter/visit.

Laterality

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.

Documentation by Clinicians Other than the Patient’s Provider

Code assignment is based on the documentation by the patient’s provider (i.e., physician
or other qualified healthcare practitioner legally accountable for establishing the
patient’s diagnosis). There are a few exceptions when code assignment may be based on
medical record documentation from clinicians who are not the patient’s provider (i.e.,
physician or other qualified healthcare practitioner legally accountable for establishing
the patient’s diagnosis). In this context, “clinicians” other than the patient’s
provider refer to healthcare professionals permitted, based on regulatory or accreditation requirements or internal hospital policies, to document in a patient’s official medical record.
These exceptions include codes for:
• Body Mass Index (BMI)
• Depth of non-pressure chronic ulcers
• Pressure ulcer stage
• Coma scale
• NIH stroke scale (NIHSS)
• Social determinants of health (SDOH)
• Laterality
• Blood alcohol level

This information is typically, or may be, documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, pressure ulcer, or a condition classifiable to category F10, Alcohol related disorders) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification. The BMI, coma scale, NIHSS, blood alcohol level codes and codes for social determinants of health should only be reported as secondary diagnoses.

Use of Sign/Symptom/Unspecified Codes

As stated in the introductory section of these official coding guidelines, a joint
effort between the healthcare provider and the coder is essential to achieve
complete and accurate documentation, code assignment, and reporting of
diagnoses and procedures. 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.

Use of Z codes

Z codes (other reasons for healthcare encounters) may be assigned as appropriate to
further explain the reasons for presenting for healthcare services, including transfers
between healthcare facilities, or provide additional information relevant to a
patient encounter.

Asymptomatic human immunodeficiency virus

Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied when the patient without any documentation of symptoms is listed as being “HIV positive,”
“known HIV,” “HIV test positive,” or similar terminology. Do not use this code if the term “AIDS” or “HIV disease” is used or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from his/her HIV positive status; use B20 in these cases.

Encounters for testing for HIV

If a patient is being seen to determine his/her HIV status, use code Z11.4, Encounter for screening for human immunodeficiency virus [HIV]. Use additional codes for any associated high-risk behavior, if applicable.

History of HIV managed by medication

If a patient with documented history of HIV disease is currently managed on antiretroviral medications, assign code B20, Human immunodeficiency virus [HIV] disease. Code Z79.899, Other long term (current) drug therapy, may be
assigned as an additional code to identify the long-term (current) use of antiretroviral medications.

Signs and symptoms without definitive diagnosis of COVID19

For patients presenting with any signs/symptoms associated with COVID-19 (such as fever, etc.) but a definitive diagnosis has not been established, assign the appropriate code(s) for each of the presenting signs and symptoms such as:
• R05.1, Acutecough, or R05.9, Cough, unspecified
• R06.02 Shortness of breath
• R50.9 Fever, unspecified

Follow-up visits after COVID-19 infection has resolved

For individuals who previously had COVID-19, without residual symptom(s) or condition(s), and are being seen for follow-up evaluation, and COVID-19 test results are negative, assign codes Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm, and Z86.16, Personal history of COVID-19.

Multisystem Inflammatory Syndrome

If an individual with a history of COVID-19 develops MIS, assign codes M35.81, Multisystem inflammatory syndrome, and U09.9, Post COVID-19 condition, unspecified.

Post COVID-19 Condition

For sequela of COVID-19, or associated symptoms or conditions that develop following a previous COVID-19 infection, assign a code(s) for the specific symptom(s) or condition(s) related to the previous COVID-19 infection, if
known, and code U09.9, Post COVID-19 condition, unspecified.
Code U09.9 should not be assigned for manifestations of an
active (current) COVID-19 infection.

If a patient has a condition(s) associated with a previous COVID-19 infection and develops a new active (current) COVID-19 infection, code U09.9 may be assigned in conjunction with code U07.1, COVID-19, to identify that the patient also has a condition(s) associated with a previous COVID-19 infection. Code(s) for the specific condition(s) associated with the previous COVID-19 infection and code(s)
for manifestation(s) of the new active (current) COVID-19 infection should also be assigned

Diabetes mellitus and the use of insulin, oral hypoglycemics,
and injectable non-insulin drugs

If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11-, Type 2 diabetes mellitus, should be assigned. Additional code(s) should be assigned from category Z79 to identify the long-term (current) use of insulin, oral hypoglycemic drugs, or injectable non-insulin antidiabetic, as follows:
If the patient is treated with both oral medications 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.

Secondary diabetes mellitus and the use of insulin, oral hypoglycemic drugs, or injectable non-insulin drugs

For patients with secondary diabetes mellitus who routinely use insulin, oral hypoglycemic drugs, or injectable non-insulin drugs, additional code(s) from category Z79 should be assigned to identify the long-term (current) use of insulin, oral hypoglycemic drugs, or non-injectable non-insulin drugs as follows:
If the patient is treated with both oral medications 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.

Medical Conditions Due to Psychoactive Substance Use, Abuse and Dependence

Medical conditions due to substance use, abuse, and dependence are not classified as substance-induced disorders. Assign the diagnosis code for the medical condition as directed by the Alphabetical Index along with the appropriate psychoactive substance use, abuse or dependence code. For example, for alcoholic pancreatitis due to alcohol dependence, assign the appropriate code from subcategory K85.2, Alcohol induced acute pancreatitis, and the appropriate code from subcategory F10.2, such as code F10.20, Alcohol dependence, uncomplicated. It would not be appropriate to assign code F10.288, Alcohol dependence with other alcohol-induced disorder.

Blood Alcohol Level

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.

Final character for trimester

Whenever delivery occurs during the current admission, and there is an “in childbirth” option for the obstetric complication being coded, the “in childbirth” code should be assigned. When the classification does not provide an obstetric code with an “in childbirth” option, it is appropriate to assign a code describing the current trimester.

Coma Scale

If multiple coma scores are captured within the first 24 hours after hospital admission, assign only the code for the score at the time of admission. ICD-10-CM does not classify coma scores that are reported after admission but less than 24 hours later.

Counseling

Code Z71.85, Encounter for immunization safety counseling, is to be used for counseling of the patient or caregiver regarding the safety of a vaccine. This code
should not be used for the provision of general information regarding risks and potential side effects during routine encounters for the administration of
vaccines.

Social Determinants of Health

Codes describing social determinants of health (SDOH) should be assigned when this information is documented.

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.

For example, coding professionals may utilize documentation of social information from social workers, community health workers, case managers, or nurses, if their documentation is included in the official medical record.

Patient self-reported documentation may 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 medical record by either a clinician or provider

Social determinants of health codes are located primarily in these Z code categories:
Z55 Problems related to education and literacy
Z56 Problems related to employment and unemployment
Z57 Occupational exposure to risk factors
Z58 Problems related to physical environment
Z59 Problems related to housing and economic circumstances
Z60 Problems related to social environment
Z62 Problems related to upbringing
Z63 Other problems related to primary support group,
including family circumstances
Z64 Problems related to certain psychosocial circumstances
Z65 Problems related to other psychosocial circumstances

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

U07.0 Vaping-related disorder 
U07.1 COVID-19 
U09.9 Post COVID-19 condition, unspecified