Industry hot topics: Insight into ambiguous, inconsistent, conflicting advice and guidance

Every month, you will find a new topic or question along with the committee’s findings posted to this page and publicized in CDI Strategies.

Topic Summary Discussion point Date posted
Comparative/ contrasting secondary conditions

The 1998 Coding Clinic instructs not to code comparative/contrasting secondary conditions as this guideline “is only for the selection of the principal diagnosis.” The 2016 Coding Clinic instructs to code these conditions if noted at the time of discharge. The current 2020 Official Guidelines for Coding and Reporting still only include specific comparative or contrasting instruction in Section II, Selection of Principal Diagnosis. Section III.C instructs to code uncertain diagnoses when documented at the time of discharge. 

Establish if both guidelines refer to all diagnoses (principal and secondary), making it appropriate to code all uncertain conditions documented at the time of discharge (the latest documentation in the stay).

Pancytopenia with febrile neutropenia A 2014 Coding Clinic says that "NCHS has agreed to address the issue of the excludes1 at category D61 at a future ICD-10-CM Coordination and Maintenance Committee (C&M) meeting". No further Coding Clinic has addressed this topic. However, the ICD-10 Official Guidelines for Coding and Reporting were published in 2015 with an Excludes 1 note exception that still stands today: “An exception to the Excludes 1 definition is the circumstance when the two conditions are unrelated to each other.” 

Determine in what circumstances queries will be generated to clarify if these conditions have separate etiologies and therefore would be appropriate to code separately. Educate using this documentation tip if needed.

Resolution: See Coding Clinic, third quarter 2020. Excludes 1 to be revised to Excludes 2. Under D61 for D70. Effective for discharges beginning October 1, 2020.


Arteriovenous malformation (AVM)

The ICD-9 and ICD-10 indexes have led/lead to a congenital nature but Coding Clinic, third quarter 2018, p. 21, instructs to code as acquired based on research. Establish at what point in time the hierarchy rule will be followed if the index and/or guideline has not been updated. 5/1/2020
Gangrene in diabetes 

I96 (gangrene, not elsewhere classified [NEC]) has an Excludes 2 note: Gangrene in diabetes (E08-E13 with .52).

There is a sub-term in the Alphabetic Index of ICD-10 under “gangrene” that states “gangrene>with diabetes.” It instructs the coder to “see diabetes, gangrene.” Based on The Official Guidelines for Coding and Reporting, the coder needs to code to the greatest level of specificity, so the coder is not able to stop at I96 but rather needs to go to the specified sub-term. When going to diabetes>gangrene as the Index instructs, the coder gets E11.52. There are no instructions under E11.52 stating to use an additional code for the gangrene.

ICD-10-CM Guideline I.B.9 states to “Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis.” In this case, the E11.52 clearly identifies all diagnoses present.

ICD-10-CM Guideline I.A.12.b states, “When an Excludes 2 note appears under a code, it is acceptable to use both the code and the excluded code together, 'when appropriate.' "

Establish when coding I96 (CC) (gangrene, NEC) with E11.52 (type II diabetes mellitus with gangrene) would be appropriate. If unsure, pose the question to the American Hospital Association (free of charge) at: 6/15/2020
Congenital conditions ICD-10-CM Official Guidelines for Coding and Reporting, I.C.17 states “Whenever the condition is diagnosed by the provider, it is appropriate to assign a code from codes Q00-Q99.” Some assume that reportable criteria is required (as stated in Guideline III), while others interpret this to mean that anytime a congenital condition is documented (and not completely corrected with past surgery), it should be coded. 

(Refer to the American Hospital Association's (AHA) Coding Clinic, first quarter 2013, p. 14: Sacral nevus on a newborn)

To avoid inconsistent data and the risk of denials, request that the National Center for Health Statistics revise Guideline I.C.17 to clarify that it is an exception to Section III. A possible clarification suggestion is:  Whenever the condition is diagnosed by the provider, it is appropriate to assign a code from codes Q00-Q99, regardless of the absence of reportable criteria or patient age.  

Requests may be e-mailed to:

Questions/comments may also be sent to CMS:

Intestinal Malabsorption with Severe Malnutrition 

Section notes for E40-E46 in the Tabular List include an Excludes 1 note for K90. 

Coding Clinic, fourth quarter 2017, pp. 108-109, instructs to assign both K90.9 and E43 for the question that was posed with a plan for others to consider revising the Excludes 1 note. 

Both Coding Clinic, fourth quarter 2019, pp. 65-66, and the Official Guidelines for Coding and Reporting, 2020 state that the instruction in the Tabular List takes precedence over the Guidelines and Coding Clinic

Coding guideline I.A. 12.a:  An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other.

When these conditions are related, E43 is not supported as a separate code. Request an update of the 2017 Coding Clinic at: 8/25/2020
Sepsis with organ dysfunction There have been no changes for this topic in the 2021 Alphabetic Index and Official Coding Guidelines (OCG). The 2021 OCG states that: “The instructions and conventions of the classification take precedence over guidelines”. Pages 11-12 instruct how to code conditions linked by “with.” Coding Clinic, fourth quarter 2019, pp. 65-66, discusses the hierarchy of conventions. Coding Clinic, fourth quarter 2017, pp. 99-100, includes “clarification of severe sepsis guideline.” There is risk that some may follow the index (with hierarchy in mind) and others may follow the OCG and Coding Clinic. It may be beneficial to request that the Cooperating Parties align all official coding resources to ensure that all are applied consistently. 9/23/2020
Right middle cerebral artery infarction and bilateral carotid artery occlusion  

Coding Clinic, third quarter 2020, pp. 28-29, instructs to code I63.231, Cerebral infarction due to unspecified occlusion or stenosis of right carotid artery, for documenation of stenotic plaque in the right carotid artery causing acute right MCA infarction. 

There is uncertainty by many as to whether I63.511, Infarction due to occlusion or stenosis of right MCA, was intentionally or unintentionally omitted or not. 

ICD-10-CM Official Guidelines for Coding and Reporting, p. 15, says: "When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code."

Consider query generation to clarify if occlusion/stenosis was present at both carotid and MCA sites. 

Consider also requesting follow-up clarification from the American Hospital Association (free of charge) at

Alcohol pancreatitis and alcohol dependence

Coding Clinic, first quarter 2020, p. 9, states that acute alcoholic pancreatitis due to alcohol dependence is not classified as an alcoholic induced disorder. 

In addition to assigning K85.20, Alcohol induced acute pancreatitis without necrosis or infection, it is advised to assign F10.20, Alcohol dependence, uncomplicated, rather than code F10.288, Alcohol dependence with other alcohol-induced disorder.

This advice appears to conflict with Coding Clinic, third quarter 2019, p. 8, which advises to assign an alcohol-induced disorder (F10.-) with G62.1, alcoholic polyneuropathy.

Consider requesting follow-up clarification from the American Hospital Association (free of charge) at 11/12/2020
Diverticulitis with peritonitis, large intestine

Code book index: Peritonitis > with diverticular disease > large intestine leads to K57.20, Diverticulitis of large intestine with perforation and abscess without bleeding.

Tabular index: There is no further code instruction pertaining to peritonitis under K57.2 or K57.20. 

Be aware of the note under the K57 category heading:

  • Code also if applicable peritonitis K65.-
Glasgow Coma Score (GCS) coding Guideline revision Code R40.2- is now limited to TBI cases according to an American Hospital Association (AHA) webinar. If coma scale codes are not permitted for non-traumatic injuries and conditions that alter neurological function, there is a risk of inaccurate or incomplete reflection of the clinical picture. The severity of illness, length of stay, and resource utilization are impacted by decreased GCS, or coma, that is not medically induced but is a result of the non-traumatic injury or condition.  Although Coding Clinic, fourth quarter 2020, p. 91, reflects the revision of the coma scale guideline, clear definitive guidance would be helpful for clarity of use, including unspecified coma. The current guideline notes that they can be used in conjunction with TBI codes. However, it does not specifically state that they are not permitted for use in other cases. Specific clarity such as p. 99 of the Official Guidelines for Coding and Reporting would be helpful: “Do not assign BMI codes during pregnancy.”  Also, GCS is one of the measures in the SOFA score, which is another negative impact of this revision.

Recommendation: E-mail to communicate these issues that may have been overlooked when this revision was created to alleviate coder confusion.  


Per Coding Clinic, November-December 1985, p. 15, pseudoseizure refers to a hysterical seizure and is coded as 300.11, Conversion disorder. 

Coding Clinic, first quarter 2021, p. 3, instructs code R56.9, Unspecified convulsions, if pseudoseizure documentation does not include "conversion disorder."

Although pseudoseizure was included in the ICD-9-CM code book index, it is not listed in the ICD-10-CM index. Be aware of the updated information with potential severity of illness (SOI) impact. 4/16/2021
Rib fracture due to CPR

Per Coding Clinic, first quarter 2013, p. 15, fractures of the rib occurring secondary to cardiopulmonary resuscitation (CPR) efforts are not classified as a complication because they are a known risk of this procedure.

Per Coding Clinic, first quarter 2021, p. 5, assign code M96.89, Other intraoperative and post procedural complications and disorders of the musculoskeletal system, as fractures of the rib are a known risk of this procedure.

Be aware of the updated information 4/16/2021