News: FY 2022 ICD-10-CM Guidelines published

CDI Strategies - Volume 15, Issue 28

The fiscal year (FY) 2022 ICD-10-CM Official Guidelines for Coding and Reporting were released on Monday, July 12, and include instructions for assigning new code U09.9, Post COVID-19 condition (found under section I.C.1/g.1.m).

According to the new Guidelines, when a patient shows signs of sequelae (late effects) of COVID-19 after the active infection has ended, you should code first the specific symptoms or sequelae, followed by code U09.9, Part B News reported. Code U09.9 is not to be used for coding the manifestations of an active COVID-19 infection.

If the patient is battling a condition associated with a previous COVID-19 infection and then develops a new active COVID-19 infection, however, the Guidelines direct coders to assign code U09.9 in conjunction with code U07.1, COVID-19, along with the specific codes for conditions associated with both the previous and new acute COVID infections.

The Guidelines also include updates that allow coders to capture codes based on documentation from clinicians other than the patient’s provider:

  • Section I.B.13 (laterality) instructs that code assignment for laterality may be based on medical record documentation from other clinicians if it is not documented by the patient’s provider. If any conflicts exist, the provider should be queried.
  • Section I.B.14 (documentation by clinicians other than the patient’s provider) allows coders to use other clinicians’ documentation to code the items below. However, the associated diagnosis must still be documented by the patient’s provider and cannot be based on other clinicians’ documentation:
    • Body mass index
    • Depth of non-pressure chronic ulcers
    • Pressure ulcer stage
    • Coma scale
    • NIH stroke scale
    • Social determinants of health (SDOH)
    • Laterality
    • Blood alcohol level
  • Section I.C.21.c.17 (SDOH) allows coders to capture SDOH codes based on documentation from any clinician involved in the patient’s care. This includes documentation from social workers, community health workers, case managers, and nurses, if their documentation is included in the official medical record. Additionally, this guideline allows code assignment based on patients’ self-reported documentation as long as it was signed-off by and incorporated into the medical record by a clinician or provider.

The Guidelines take effect October 1, 2021, along with the finalized FY 2022 code set. Note that the FY 2022 ICD-10-PCS Guidelines were also recently released with limited updates.

Editor’s note: To read Part B News’ coverage of the new guidelines, click here. To read about the FY 2022 code set, click here.

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Clinical & Coding, News

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