Twelve new official guidelines that affect CDI

Why This Topic Matters

The article helps readers understand which guideline updates may change documentation review, query practices, and code assignment workflows. It is especially relevant for teams tracking ICD-10-CM/PCS guidance, CDI quality monitoring, and documentation specificity requirements.

Article Sections

1. Introduction

   Sets the context for a year of coding and documentation changes and explains why the guideline updates are important for CDI professionals.

2. Excludes1 notes: section A.12.a

   Discusses guideline clarification related to Excludes1 notes and when provider clarification may be needed for potentially related conditions.

3. The term ‘with’: section A.15

   Covers general documentation linkage concepts in the classification when conditions are joined by relational terms.

4. Clinical criteria: section A.19

   Explains the role of provider diagnostic statements versus clinical criteria in diagnosis assignment and CDI review.

5. Documentation from non-providers: section B.14

   Addresses how documentation from non-physician sources can support certain qualifying clinical details when the diagnosis is documented.

6. Zika virus code assignment: section 1.f.1

   Summarizes guidance related to confirmation of the diagnosis and the reporting of a then-current infectious disease issue.

7. Long-term use of oral hypoglycemic with diabetes: section 4.a.1.3

   Reviews a guideline update involving long-term medication use in the diabetes coding context.

8. Hypertension, heart disease, chronic kidney disease: Section 9.a

   Covers relationship assumptions involving hypertension and certain associated conditions, along with when additional documentation is needed.

9. Hypertensive crisis: Section 9.a.10

   Discusses the guideline update for documented hypertensive crisis presentations and related sequencing considerations.

10. Pressure ulcers: Section 12.a.5 and 12.a.6

    Addresses pressure ulcer staging and reporting across admission and discharge when wound status changes during the encounter.

11. Coma scale: Section 18.e

    Covers expanded use of the Glasgow coma scale beyond trauma-related situations.

12. NIHSS: Section 18.i

    Explains updated use of stroke scale reporting in conjunction with stroke-related diagnosis coding and sequencing.

13. Open fractures/Gustilo-Anderson classification: Section 19.c.1

    Summarizes guidance related to open fracture classification and seventh-character reporting under ICD-10-CM.

14. Summary

    Wraps up the article’s main message about keeping current with guideline and documentation changes affecting CDI work.