Primary Care Coding Alert

You’ll soon be able to report laterality when clinicians other than your provider note it.

The Centers for Disease Control and Prevention (CDC) has made some small changes to the 2022 ICD-10 coding guidelines that may have a big impact on your documentation practices when they take effect on Oct. 1, 2021.

Here are the highlights along with some great insights from two of our experts.

Enjoy More Autonomy When Documenting Laterality, SDoH, Blood Alcohol

Prior to the 2022 ICD-10 general coding guideline revisions, you were able to document the patient’s body mass index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes based on information in the patient’s medical record recorded by clinicians other than the patient’s provider, which the guidelines define as the “physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis.”

Now, a revision to guideline 1.B.13 will let you add laterality to that list. The revised guideline tells you that “code assignment for the affected side may be based on medical record documentation from other clinicians.” And because of a related change to guideline 1.B.14, you’ll also be able to document a patient’s social determinants of health (SDoH) and blood alcohol level under similar circumstances.

These revisions have been met with unanimous approval. “I think 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. “It will also help to reduce the unspecified coding problem,” Johnson adds.

Additionally, “the new language in I.B.14 complements that in I.B.13 and provides 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, though the language makes clear that while other clinicians may document the data points listed, the patient’s provider is still responsible for documenting the associated diagnosis, especially if there’s any question or conflict,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

But be careful: The revision to 1.B.13 tells you that you should “rarely” use an unspecified side code unless “documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification.”

The revision to guideline 1.B.14 also tells you that codes for BMI, coma scale, NIHSS, blood alcohol level, and SDoH must only be reported as secondary diagnoses and that any associated diagnoses “(such as overweight, obesity, acute stroke, pressure ulcer, or a condition classifiable to category F10, Alcohol related disorders) must be documented by the patient’s provider.”

Note This New Way to Code COVID Follow-Ups

New guidelines specific to COVID-19 follow-up visits tell you that the patient must be “without residual symptom(s) or condition(s) … and COVID-19 test results are negative” for you to code the follow-up evaluation with Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) and Z86.16 (Personal history of COVID-19) after the patient’s COVID-19 condition has resolved.

And guideline 1.C.g.1.m. goes on to tell you to use new code U09.9 (Post COVID-19 condition, unspecified)

• “for sequela of COVID-19, or associated symptoms or conditions that develop following a previous COVID-19 infection” along with a “code(s) for the specific symptom(s) or condition(s) related to the previous COVID-19 infection, if known”; and
• with U07.1 (COVID-19), along with “code(s) for the specific condition(s) associated with the previous COVID-19 infection and code(s) for manifestation(s) of the new active (current) COVID-19 infection … if a patient has a condition(s) associated with a previous COVID-19 infection and develops a new active (current) COVID-19 infection.”

“The new and specified post COVID-19 condition code U09.9 will be very helpful, as will the official and specific guidelines for COVID coding in general,” says Johnson.

Master HIV Medication Coding With This Update

A revision to guideline 1.C.1.a.2.i. gives you explicit instructions for documenting when a patient’s human immunodeficiency virus (HIV) is being managed by medication. Moving forward, you’ll use B20 (Human immunodeficiency virus [HIV] disease) and assign Z79.899 (Other long term (current) drug therapy) “as an additional code to identify the long-term (current) use of antiretroviral medications.”

“With more patients with HIV living longer thanks to medications, this is an important addition and one that PCPs who care for such patients should be aware of,” says Moore.

Use This New Guideline With New Code Z71.85

The last highlight is an addition to guideline I.C.21.c.10 to accompany brand-new code Z71.85 (Encounter for immunization safety counseling). The addition instructs you that the code “should not be used for the provision of general information regarding risks and potential side effects during routine encounters for the administration of vaccines,” but for “counseling of the patient or caregiver regarding the safety of a vaccine.”

You can find the updated 2022 ICD-10 Guidelines by going to ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2022/10cmguidelines-FY2022-7-2022-7-15-21-update-508.pdf.