A summary of the modifications ICD-10-CM Official Guidelines for Coding and Reporting are included below. The complete guidelines may be downloaded by visiting http://www.cdc.gov/nchs/icd/icd10cm.htm
The modifications are published below using the following format:
Narrative changes appear in bold text (e.g., severe sepsis)
Items underlined have been moved within the guidelines since
October 1, 2017 (e.g., severe sepsis)
Deletions are shown as strikeouts (e.g., severe sepsis)
Section I. Conventions, general coding guidelines and chapter specific guidelines . . .
A. Conventions for the ICD-10-CM . . .
The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly associated with the sepsis”).
For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related. . . .
17. “Code also” note
A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter. . . .
B. General Coding Guidelines . . .
7. Multiple coding for a single condition
In addition to the etiology/manifestation convention that requires two codes to fully describe a single condition that affects multiple body systems, there are other single conditions that also require more than one code. “Use additional code” notes are found in the Tabular List at codes that are not part of an etiology/manifestation pair where a secondary code is useful to fully describe a condition. The sequencing rule is the same as the etiology/manifestation pair, “use additional code” indicates that a secondary code should be added, if known. . . .
“Code first” notes are also under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When there is a “code first” note and an underlying condition is present, the underlying condition should be sequenced first, if known. . . .
C. Chapter Specific Coding Guidelines . . .
General guidelines . . .
Malignant neoplasm of ectopic tissue
Malignant neoplasms of ectopic tissue are to be coded to the site of origin mentioned, e.g., ectopic pancreatic malignant neoplasms involving the stomach are coded to malignant neoplasm of pancreas, unspecified (C25.9). . . .
a. Treatment directed at the malignancy
If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis.
The only exception to this guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or external beam radiation therapy, assign the appropriate Z51.-- code as the first-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis. . . .
e. Admissions/Encounters involving chemotherapy, immunotherapyand radiation therapy . . .
2) Patient admission/encounter solely for administration of chemotherapy, immunotherapy and radiation therapy
If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or external beam radiation therapy assign code Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy as the first listed or principal diagnosis. . . .
If a patient admission/encounter is for the insertion or implantation of radioactive elements (e.g., brachytherapy) the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis. Code Z51.0 should not be assigned.
3) Patient admitted for radiation therapy, chemotherapy or immunotherapy and develops complications
When a patient is admitted for the purpose of external beam radiotherapy, immunotherapy or chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first listed diagnosis is Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy followed by any codes for the complications.
When a patient is admitted for the purpose of insertion or implantation of radioactive elements (e.g., brachytherapy) and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first listed diagnosis is the appropriate code for the malignancy followed by any codes for the complications. . . .
a. Diabetes mellitus
3) Diabetes mellitus and the use of insulin and oral hypoglycemics
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. Code Z79.4, Long term (current) use of insulin or Z79.84, Long term (current) use of oral hypoglycemic drugs, should also be assigned to indicate that the patient uses insulin or hypoglycemic drugs. An additional code should be assigned from category Z79 to identify the long-term (current) use of insulin or oral hypoglycemic drugs. If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of insulin should be assigned. Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient’s blood sugar under control during an encounter. . . .
6) Secondary diabetes mellitus . . .
(a) Secondary diabetes mellitus and the use of insulin or oral hypoglycemic drugs
For patients with secondary diabetes mellitus who routinely use insulin or oral hypoglycemic drugs, an additional code Z79.4, Long-term (current) use of insulin, or Z79.84, Long term (current) use of oral hypoglycemic drugs from category Z79 should be assigned to identify the long-term (current) use of insulin or oral hypoglycemic drugs should also be assigned. If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of insulin should be assigned. Code Z79.4 should not be assigned if insulin is given temporarily to bring a secondary diabetic patient’s blood sugar under control during an encounter. . . .
b. Mental and behavioral disorders due to psychoactive substance use
1) In Remission
Selection of codes for “in remission” for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -11, -.21) requires the provider’s clinical judgment. The appropriate codes for “in remission” are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting), unless otherwise instructed by the classification.
Mild substance use disorders in early or sustained remission are classified to the appropriate codes for substance abuse in remission, and moderate or severe substance use disorders in early or sustained remission are classified to the appropriate codes for substance dependence in remission. . . .
3) Psychoactive Substance Use Disorders
As with all other diagnoses, the codes for psychoactive substance use disorders (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). The codes are to be used only when the psychoactive substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the provider. . . .
If “blindness” or “low vision” of both eyes is documented but the visual impairment category is not documented, assign code H54.3, Unqualified visual loss, both eyes. If “blindness” or “low vision” in one eye is documented but the visual impairment category is not documented, assign a code from H54.6-, Unqualified visual loss, one eye. If “blindness” or “visual loss” is documented without any information about whether one or both eyes are affected, assign code H54.7, Unspecified visual loss. . . .
1) Hypertension with Heart Disease
Hypertension with heart conditions classified to I50.- or I51.4-I51.9, are assigned to a code from category I11, Hypertensive heart disease. Use an additional code(s) from category I50, Heart failure, to identify the type(s) of heart failure in those patients with heart failure. . . .
11) Pulmonary Hypertension
Pulmonary hypertension is classified to category I27, Other pulmonary heart diseases. For secondary pulmonary hypertension (I27.1, I27.2-), code also any associated conditions or adverse effects of drugs or toxins. The sequencing is based on the reason for the encounter.
e. Acute myocardial infarction (AMI)
1) Type 1 ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI)
The ICD-10-CM codes for type 1 acute myocardial infarction (AMI) identify the site, such as anterolateral wall or true posterior wall. Subcategories I21.0-I21.2 and code I21.3 are used for type 1 ST elevation myocardial infarction (STEMI). Code I21.4, Non-ST elevation (NSTEMI) myocardial infarction, is used for type 1 non ST elevation myocardial infarction (NSTEMI) and nontransmural MIs.
If a type 1 NSTEMI evolves to STEMI, assign the STEMI code. If a type 1 STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI. . . .
2) Acute myocardial infarction, unspecified
Code I21.3, ST elevation (STEMI) myocardial infarction of unspecified site, I21.9, Acute myocardial infarction, unspecified, is the default for unspecified acute myocardial infarction or unspecified type. If only type 1 STEMI or transmural MI without the site is documented, assign code I21.3, ST elevation (STEMI) myocardial infarction of unspecified site. . . .
4) Subsequent acute myocardial infarction
A code from category I22, Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction, is to be used when a patient who has suffered a type 1 or unspecified AMI has a new AMI within the 4 week time frame of the initial AMI. A code from category I22 must be used in conjunction with a code from category I21. The sequencing of the I22 and I21 codes depends on the circumstances of the encounter.
Do not assign code I22 for subsequent myocardial infarctions other than type 1 or unspecified. For subsequent type 2 AMI assign only code I21.A1. For subsequent type 4 or type 5 AMI, assign only code I21.A9.
5) Other Types of Myocardial Infarction
Type 2 myocardial infarction, and myocardial infarction due to demand ischemia or secondary to ischemic balance, is assigned to code I21.A1, Myocardial infarction type 2 with a code for the underlying cause. Do not assign code I24.8, Other forms of acute ischemic heart disease for the demand ischemia. Sequencing of type 2 AMI or the underlying cause is dependent on the circumstances of admission. When a type 2 AMI code is described as NSTEMI or STEMI, only assign code I21.A1. Codes I21.01-I21.4 should only be assigned for type 1 AMIs.
Acute myocardial infarctions type 3, 4a, 4b, 4c and 5 are assigned to code I21.A9, Other myocardial infarction type.
The “Code also” and “Code first” notes should be followed related to complications, and for coding of postprocedural myocardial infarctions during or following cardiac surgery.
a. Pressure ulcer stage codes
6) Patient admitted with pressure ulcer evolving into another stage during the admission
If a patient is admitted to an inpatient hospital with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.
b. Non-Pressure Chronic Ulcers
1) Patients admitted with non-pressure ulcers documented as healed
No code is assigned if the documentation states that the non-pressure ulcer is completely healed.
2) Patients admitted with non-pressure ulcers documented as healing
Non-pressure ulcers described as healing should be assigned the appropriate non-pressure ulcer code based on the documentation in the medical record. If the documentation does not provide information about the severity of the healing non-pressure ulcer, assign the appropriate code for unspecified severity.
If the documentation is unclear as to whether the patient has a current (new) non-pressure ulcer or if the patient is being treated for a healing non-pressure ulcer, query the provider.
For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and severity of the non-pressure ulcer at the time of admission.
3) Patient admitted with non-pressure ulcer that progresses to another severity level during the admission
If a patient is admitted to an inpatient hospital with a non-pressure ulcer at one severity level and it progresses to a higher severity level, two separate codes should be assigned: one code for the site and severity level of the ulcer on admission and a second code for the same ulcer site and the highest severity level reported during the stay. . . .
c. Coding of Pathologic Fractures . . .
7th character D is to be used for encounters after the patient has completed active treatment for the fracture and is receiving routine care for the fracture during the healing or recovery phase. The other 7th characters, listed under each subcategory in the Tabular List, are to be used for subsequent encounters for routine care of fractures during the healing and recovery phase as well as treatment of problems associated with the healing, such as malunions, nonunions, and sequelae. . . .
h. Long term use of insulin and oral hypoglycemics
Code Z79.4, Long-term (current) use of insulin, or code Z79.84, Long-term (current) use of oral hypoglycemic drugs, should also be assigned if the diabetes mellitus is being treated with insulin or oral medications. If the patient is treated with both oral medications and insulin, only the code for insulin-controlled should be assigned.
See section I.C.4.a.3 for information on the long term use of insulin and oral hypoglycemic. . . .
q. Termination of Pregnancy and Spontaneous abortions . . .
1) Retained Products of Conception following an abortion
Subsequent encounters for retained products of conception following a spontaneous abortion or elective termination of pregnancy, without complications are assigned the appropriate code from category O03, Spontaneous abortion.O03.4, Incomplete spontaneous, abortion without complication, or codes O07.4, Failed attempted termination of pregnancy without complication. and Z33.2, Encounter for elective termination of pregnancy. This advice is appropriate even when the patient was discharged previously with a discharge diagnosis of complete abortion. If the patient has a specific complication associated with the spontaneous abortion or elective termination of pregnancy in addition to retained products of conception, assign the appropriate complication in category O03 or O07 instead of code O03.4 or O07.4.
2) Complications leading to abortion
b. Observation and Evaluation of Newborns for Suspected Conditions not Found
1) Use of Z05 codes
Assign a code from category Z05, Observation and evaluation of newborns and infants for suspected conditions ruled out, to identify those instances when a healthy newborn is evaluated for a suspected condition that is determined after study not to be present. Do not use a code from category Z05 when the patient has identified signs or symptoms of a suspected problem; in such cases code the sign or symptom.
2) Z05 on Other than the Birth Record
A code from category Z05 may also be assigned as a principal or first-listed code for readmissions or encounters when the code from category Z38 code no longer applies. Codes from category Z05 are for use only for healthy newborns and infants for which no condition after study is found to be present.
f. Functional quadriplegia
Functional quadriplegia (code R53.2) is the lack of ability to use one’s limbs or to ambulate due to extreme debility. It is not associated with neurologic deficit or injury, and code R53.2 should not be used for cases of neurologic quadriplegia. It should only be assigned if functional quadriplegia is specifically documented in the medical record.
GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1, 2017.
b. Coding of Injuries
When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. Codes from category T07, Unspecified multiple injuries, should not be assigned in the inpatient setting unless information for a more specific code is not available. Traumatic injury codes (S00-T14.9) are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds.
c. Categories of Z Codes
4) History (of) . . .
The history Z code categories are:
Z91.8- Other specified personal risk factors, not elsewhere classified
xception: Z91.83, Wandering in diseases classified elsewhere
Z91.81 History of falling
Z91.82 Personal history of military deployment
10) Counseling . . .
Counseling Z codes are used when a patient or family member receives assistance in the aftermath of an illness or injury, or when support is required in coping with family or social problems. They are not used in conjunction with a diagnosis code when the counseling component of care is considered integral to standard treatment.
The counseling Z codes/categories:
Z31.5 Encounter for procreative genetic counseling
11) Encounters for Obstetrical and Reproductive Services . . .
Codes in category Z3A, Weeks of gestation, may be assigned to provide additional information about the pregnancy. Category Z3A codes should not be assigned for pregnancies with abortive outcomes (categories O00-O08), elective termination of pregnancy (code Z33.32 Z33.2), nor for postpartum conditions, as category Z3A is not applicable to these conditions. The date of the admission should be used to determine weeks of gestation for inpatient admissions that encompass more than one gestational week. . . .
14) Miscellaneous Z codes . . .
Miscellaneous Z codes/categories: . . .
Z91.84-Oral health risk factors . . .
16) Z Codes That May Only be Principal/First-Listed Diagnosis . . .
Z40 Encounter for prophylactic surgery
Section II. Selection of Principal Diagnosis . . .
K. Admissions/Encounters for Rehabilitation . . .
If the condition for which the rehabilitation service is being provided is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis, unless the rehabilitation service is being provided following an injury. For rehabilitation services following active treatment of an injury, assign the injury code with the appropriate seventh character for subsequent encounter as the first-listed or principal diagnosis. For example, if a patient with severe degenerative osteoarthritis of the hip, underwent hip replacement and the current encounter/admission is for rehabilitation, report code Z47.1, Aftercare following joint replacement surgery, as the first-listed or principal diagnosis. If the patient requires rehabilitation post hip replacement for right intertrochanteric femur fracture, report code S72.141D, Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, as the first-listed or principal diagnosis.
See Section I.C.21.c.7, Factors influencing health states and contact with health services, Aftercare.
See Section I.C.19.a for additional information about the use of 7th characters for injury codes.
Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services . . .
P. Encounters for general medical examinations with abnormal findings
Present on Admission Reporting Guidelines
Introduction . . .
Please see the CDC website for the detailed list of ICD-10-CM codes that do not require the use of a POA indicator
(https://www.cdc.gov/nchs/icd/icd10cm.htm) (https://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-CM-and-GEMs.html). The conditions codes and categories on this exempt list represent categories and/or codes are for circumstances regarding the healthcare encounter or factors influencing health status that do not represent a current disease or injury or that describe conditions that are always present on admission.