AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2018 Issue 4
Changes to the ICD-10-CM Official Guidelines for Coding and Reporting
A summary of the modifications to the 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 were moved within the guidelines since October 1, 2018 (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 . . . 15. “With” The word “with” or “in” should be...
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Article Overview
This article reviews selected changes to the ICD-10-CM Official Guidelines for Coding and Reporting. It is relevant to coders, CDI professionals, compliance teams, and others who work with diagnosis coding rules and reporting guidance. The discussion spans conventions, documentation and sequencing guidance, and chapter-specific updates involving infectious diseases, neoplasms, mental health, eye, circulatory, skin, pregnancy, symptoms, injury, and Z code reporting.
Why This Topic Matters
These guideline updates affect how diagnosis coding guidance is interpreted and reported across a wide range of clinical scenarios. Understanding the scope of the changes helps coding and compliance staff stay aligned with current ICD-10-CM reporting expectations.
Article Sections
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Section I. Conventions, general coding guidelines and chapter specific guidelines
Introduces the guideline update format and the major sections covered in the article. It frames the types of changes discussed across ICD-10-CM guidance.
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Section I.C.1. Chapter 1: Certain Infectious and Parasitic Diseases
Covers infectious disease-related guideline updates, including postprocedural infection, sepsis, septic shock, and Zika-related reporting.
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Section I.C.2. Chapter 2: Neoplasms
Addresses updates related to malignancy status and the use of history codes for prior cancers.
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Section I.C.5. Chapter 5: Mental, Behavioral and Neurodevelopmental disorders
Summarizes guidance for substance-related disorders and factitious disorder reporting, including cases involving another person.
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Section I.C.7. Chapter 7: Diseases of the Eye and Adnexa
Describes guidance related to glaucoma reporting, including bilateral cases and laterality distinctions.
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Section I.C.9. Chapter 9: Diseases of the Circulatory System
Reviews guideline updates for hypertension, chronic kidney disease, pulmonary hypertension, and myocardial infarction reporting.
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Section I.C.12. Chapter 12: Diseases of the Skin and Subcutaneous Tissue
Covers pressure ulcer and non-pressure chronic ulcer guidance, including staging and progression during an admission.
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Section I.C.15. Chapter 15: Pregnancy, Childbirth, and the Puerperium
Summarizes guidance for drug use during pregnancy, childbirth, and the puerperium.
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Section I.C.18. Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified
Covers documentation and reporting guidance for coma scale and NIHSS stroke scale information.
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Section I.C.19. Chapter 19: Injury, poisoning, and certain other consequences of external causes
Addresses burn and corrosion reporting, underdosing, abuse-related encounters, and other injury-related external cause guidance.
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Section I.C.21. Chapter 21: Factors influencing health status and contact with health services
Reviews updates to Z code categories, including BMI, status codes, and other miscellaneous health-status reporting guidance.
What You Will Learn
- How the article organizes recent ICD-10-CM guideline modifications
- Which major ICD-10-CM chapters are affected by the updates
- What broad types of documentation and sequencing guidance are addressed
- How the article frames reporting issues involving injuries, infections, chronic conditions, pregnancy, and Z codes
Who Should Read This
- Medical coders
- Coding educators
- Clinical documentation improvement professionals
- Compliance staff
- Revenue cycle teams
- Healthcare auditors
Codes Discussed
Code Ranges Discussed
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