ICD 10 Coding Alert

Code Update:

Report Affected Sides Sans Provider Documentation in These Situations

Published on Mon Oct 04, 2021

Hint: Sometimes you may be able to lean on other clinicians’ additions to the medical record.

October is here, and the 2022 ICD-10-CM guidelines are now in effect. Make sure your coding is accurate.

Reporting Breast Implant Associated Anaplastic Large Cell Lymphoma? Do This

The first main change to the 2022 ICD-10-CM involves how you will code breast implant associated anaplastic large cell lymphoma, or BIA-ALCL, “a type of non-Hodgkin’s lymphoma (cancer of the immune system) … found in the scar tissue and fluid near the implant [that] can spread throughout the body” (www.fda.gov/medical-devices/breast-implants/questions-and-answers-about-breast-implant-associated-anaplastic-large-cell-lymphoma-bia-alcl).

Given its cause, you might be tempted to use a code from T85.- (Complications of other internal prosthetic devices, implants and grafts), which could lead you to use a code such as T85.79- (Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts) or even T85.43- (Leakage of breast prosthesis and implant).

However, as the Food and Drug Administration (FDA’s) definition of BIA-ALCL notes, the condition is more than a complication of a breast implant: It’s a form of lymphoma. That’s why the Centers for Disease Control and Prevention (CDC) has issued the guidance detailed in the new guideline, I.C.2.s, that you should “not assign a complication code from chapter 19 [Injury, poisoning and certain other consequences of external causes]” and instead assign new code C84.7A (Anaplastic large cell lymphoma, ALK-negative, breast) for BIA-ALCL.

Don’t forget: The code C84.7A “comes with the synonym of breast implant associated anaplastic large cell lymphoma[(BIA-ALCL] and ‘Use additional’ notes that tell you to identify breast implant status [Z98.82] and personal history of breast implant removal (Z98.86),” according to Amy Pritchett, CCS, CPC-I, CPMA, CDEO, CASCC, CANPC, CRC, CDEC, CMPM, C-AHI, senior consultant at Pinnacle Enterprise Risk Consulting Services LLC in Centennial, Colorado.

Relax About These Documentation Factors by Other Providers

The 2022 ICD-10-CM guideline revisions now “provide a clear list of the things for which coders can use other clinicians’ documentation. The revisions give coders more latitude on what they can use in the medical record,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

First, the revision to guideline I.B.14 clarifies those other clinicians: They are “healthcare professionals permitted, based on regulatory or accreditation requirements or internal hospital policies, to document in a patient’s official medical record.” Or, to put it another way, they are clinicians other than the patient’s provider who are “legally accountable for establishing the patient’s diagnosis.”

Next, the guideline more clearly outlines the list of exceptions where code assignment may be based on documentation from clinicians who are not the patient’s provider. They previously included patient’s body mass index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes. Additionally, you could also report codes for social determinants of health (SDoH) when the information was provided by clinicians other than the patient’s provider and/or if the information was self-reported by the patient “as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider.”

Remember, the new guidelines went into effect Oct. 1, 2021, so you can add blood alcohol level to that list along with laterality, thanks to a major addition to guideline I.B.13.

For oncology coders, “this is a great update and a reasonable allowance when laterality can be reasonably related,” argues Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

But you should note the following caveats before inferring laterality, or any of the other medical or social conditions, from the medical record:

1. While the new guideline “will help to reduce your use of unspecified codes” according to Johnson, the guideline notes you may have to use such a code when “documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification.”

2. The guideline also cautions that “if there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.”

3. The guideline also clarifies that “the BMI, coma scale, NIHSS, blood alcohol level codes and codes for social determinants of health should only be reported as secondary diagnoses.”

4. And lastly, “the patient’s provider must document any associated diagnosis, such as overweight, obesity, acute stroke, or pressure ulcer” says Leah Fuller, senior consultant at Pinnacle Enterprise Risk Consulting Services LLC in Centennial, Colorado.

(To view the updated ICD-10-CM guidelines for 2022, head to ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2022/10cmguidelines-FY2022-7-2022-7-15-21-update-508.pdf).