This is a summary of updates made to ICD-10-CM Official Guidelines for Coding and Reporting for fiscal year (FY) 2023, effective Oct. 1, 2022, through Sept. 30, 2023. Changes to narratives or explanations impacting guidelines appear in bold text. Revisions made on section headings noted as “See Section” and appear in italics.
There are new section headings and will appear in bold and italics as “See Section”. Carefully review FY 2023 guideline updates as it can impact appropriate coding and billing practices.
Below is a list of FY 2023 updated guidelines:
Section 1.A.13 Etiology/manifestation convention (“code first”, “use additional code” and “in diseases classified elsewhere” notes) clarifies coding dementia with Parkinson’s disease.
Section 1.A.19 Code assignment and Clinical Criteria provides instructions on provider query if provider documents conflicting information.
General coding guidelines
Section 1.B.14 Documentation by Clinicians Other than the Patient’s Provider has an added exception based on other healthcare professional’s documentation to include underimmunization status. There’s also explanation on coding underimmunization status as secondary diagnosis. See Section I.C.21.c.17. for additional information regarding coding social determinants of health.
Section 1.B.16 Documentation of Complication of Care furnishes thorough explanation on case-and effect relationship and clinical correlation. 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. Query the provider for clarification if the documentation is not clear as to the relationship between the condition and the care or procedure.
Chapter-specific coding guidelines
Chapter 1. Certain Infectious and Parasitic Diseases (A00-B99), U07.1, U09.9Section 1.C.1.a.2(a)
Selection and sequencing of HIV codes presents and exception to the guideline on HIV-related condition coding. 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.
Section 1.C.1.a.2(i) HIV managed by antiretroviral medication identifies HIV-related illness or AIDS is documented as managed by antiretroviral medications code assignment.
Section 1.C.1.d(9) Explanation of sequencing Hemolytic-uremic syndrome associated with sepsis. 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.
Section 1.C.1.g.1(n) Added heading See Section I.B.14. for underimmunization documentation by clinicians other than patient's provider.
Chapter 2. Neoplasms (C00-D49)
Section 1.C.2.a Admission/Encounter for treatment of primary site has added definition of primary site and sequencing:
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.
The only exception to this guideline is if the administration of chemotherapy, immunotherapy or external beam radiation therapy is chiefly responsible for occasioning the admission/encounter. In that case, assign the appropriate Z51.-- code as the first-listed or principal diagnosis, and the underlying diagnosis or problem for which the service is being performed as a secondary diagnosis.
Section 1.C.2.t is a new guideline enhancing coding of secondary malignant neoplasm tissue. When a malignant neoplasm of lymphoid tissue metastasizes beyond the lymph nodes, a code from categories C81-C85 with a final character “9” should be assigned identifying “extranodal and solid organ sites” rather than a code for the secondary neoplasm of the affected solid organ. For example, for metastasis of B-cell lymphoma to the lung, brain and left adrenal gland, assign code C83.39, Diffuse large B-cell lymphoma, extranodal and solid organ sites.
Chapter 4. Endocrine, Nutritional, and Metabolic Diseases (E00-E89)
Section 1.C.4.a.3 includes oral hypoglycemic drug status and Z79.85, Long-term (current) use of injectable non-insulin antidiabetic drugs relative to diabetes mellitus.
Section 1.C.4.a.6(a) is in relation to secondary diabetes mellitus and use of oral hypoglycemic drugs as well as Z79.85, Long-term (current) use of injectable non-insulin antidiabetic drugs.
Chapter 5. Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)
Section 1.C.5.b.1 has supplementary terms such as describing “in remission” as well as and linking clinical judgement and provider documentation. Also, categories F10-F19 includes new -.91.
Section 1.C.5.d is new language in relation to dementia. 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.
Chapter 15. Pregnancy, Childbirth, and the Puerperium (O00-O9A)
Section 1.C.15.a.7 applies to completed weeks of gestation. In ICD-10-CM, “completed” weeks of gestation refers to full weeks. 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.
Section 1.C.15.q.4 on hemorrhage following elective abortion added clarification on code assignment. For hemorrhage post elective abortion, assign code O04.6, Delayed or excessive hemorrhage following (induced) termination of pregnancy. Do not assign code O72.1, Other immediate postpartum hemorrhage, as this code should not be assigned for post abortion conditions. Do not assign code Z33.2, Encounter for elective termination of pregnancy, when the patient experiences a complication post elective abortion.
Chapter 16. Certain Conditions Originating in the Perinatal Period (P00-P96)
Section 1.C.16.b.1 under observation and evaluation of newborns for suspected conditions not found has some added wording on use of Z05.
Chapter 19. Injury, poisoning, and certain other consequences of external causes (S00-T88)
Section 1.C.19.e.5(c) clarifies documentation requirements for underdosing. 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.
Chapter 21. Factors influencing health status and contact with health services (Z00-Z99)
Section 1.C.21.c.10 regarding z codes on counseling, has supplemented information on transition counseling from pediatric-to-adult. 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.
Section 1.C.21.c.14 clarifies Z73 problems related to life management difficulty. Note: These codes should be assigned only when the documentation specifies that the patient has an associated problem.
Section 1.C.21.c.17 defines rationale on assigning codes describing social determinants of health. Codes describing problems or risk factors related to social determinants of health (SDOH) should be assigned when this information is documented. 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.