By Karen M. Linder, RHIT, CCS, CCS-P, CHDA
Fiscal year (FY) 2018 ICD-10-CM updates will keep coding professionals busy with approximately 360 new codes, 142 deletions, and 226 code revisions posted by the National Center for Health Statistics (NCHS) on the Centers for Disease Control and Prevention (CDC) website. Due to the numerous new/revised codes, Tabular List, and alphabetical index changes, this article will highlight only a portion of the updates to the ICD-10-CM classification and the ICD-10-CM Official Guidelines for Coding and Reporting approved for FY 2018. For the complete addenda and guidelines please see the resource links at the end of this article.
ICD-10-CM Code Updates for FY 2018
Enterocolitis due to Clostridium difficile (A04.71–A04.72) will now need to be further specified as recurrent or not with an additional fifth digit. The title of C96.2- Malignant mast cell tumor has been revised to malignant mast cell neoplasm and expanded to create these codes:
- C96.20 Malignant mast cell neoplasm, unspecified
- C96.21 Aggressive systemic mastocytosis
- C96.22 Mast cell sarcoma
- C96.29 Other malignant mast cell neoplasm
Code D47.0 has been expanded to D47.01, Cutaneous mastocytosis, D47.02, Systemic mastocytosis, and D47.09, Other mast cell neoplasms of uncertain behavior.
The advice from the American Hospital Association’s Coding Clinic in its first quarter 2013 and second quarter 2016 publications regarding Diabetes mellitus with ketoacidosis is no longer valid, with the creation of a new code/subcategory to describe Diabetes mellitus with ketoacidosis without coma (E11.10) and with coma (E11.11). Code E85.8, Other amyloidosis has been expanded to five characters to include Light chain (AL) (E85.81), Wild-type transthyretin-related (ATTR) (E85.82), and Other amyloidosis (E85.89).
It is now possible to select a specific ICD-10-CM code when a patient is in remission from abuse of each of a variety of substances such as alcohol, opioids, cannabis, sedative, hypnotic or anxiolytic-related, cocaine, hallucinogen, inhalant, nicotine, and other psychoactive substance related disorders. The new “in remission” codes all end with .11.
New codes have been added for Primary lateral sclerosis (G12.23), Familial motor neuron disease (G12.24), and Progressive spinal muscle atrophy (G12.25). Code category G47, Sleep disorders now contains additional descriptions to further specify additional disorders included in several of the existing codes. If toxic encephalopathy (G92) is drug-induced, T36-T50 will need to be coded first per the new “Code first” note added in the Tabular List.
At code category H42, Glaucoma in diseases classified elsewhere, the Excludes2 note “glaucoma (in) diabetes mellitus (E08.39, E09.39, E10.39, E11.39, E13.39)” has changed to a “Code first” note. Code H44.2, Degenerative myopia has new codes (H44.2A1–H44.2E9) to provide more specification for conditions present with the degenerative myopia such as choroidal neovascularization, macular hole, retinal detachment, foveoschisis, maculopathy, or other maculopathy with laterality specifications for each. Codes in category H54, Blindness and low vision have been expanded to include different category levels of vision for each eye and whether they are the same or different in each eye. Be sure to review the new coding guideline related to blindness (I.C.7.b.).
Code category I11, Hypertensive heart disease revised the Includes note to now include code I50.-. You will need to take into consideration the type of myocardial infarction (MI) the patient is having with new codes for myocardial infarction type 2 (I21.A1) and other myocardial infarction type (I21.A9). A type 2 MI describes a myocardial infarction due to demand ischemia. In addition, notes added under ST-elevation MI codes (I21.0–I21.4) clarify that the condition is a type 1 MI. Other secondary pulmonary hypertension (I27.2) has been expanded to five characters. Carefully review the Tabular List for the specific codes.
Code I27.8, Other specified pulmonary heart disease was expanded to include Eisenmenger’s syndrome (I27.83) with instructions to also code the underlying heart defect.
There are several new codes for different types of heart failure such as:
- Acute right heart failure (I50.811)
- Acute on chronic right heart failure (I50.813)
- Right heart failure due to left heart failure (I50.814)
- High output heart failure (I50.83)
- End-stage heart failure (I50.84)
End-stage heart failure is assigned for patients with an advanced form of the disease who no longer respond to medication.
J09, Influenza due to certain identified influenza viruses has a new Excludes1 note: “influenza A/H1N1 (J10.-).” Code J44.0, Chronic obstructive pulmonary disease with acute lower respiratory infection changed the “Use Additional code to identify the infection” note to a “Code also” note. This could impact code sequencing if an infection is documented; carefully review the definitions of these notes in the guidelines.
Gingival recession code K06.0 was expanded to specify localized (K06.010–K06.013) or generalized (K06.020–K06.023). Intestinal adhesions (bands) with obstruction (postinfection) (K56.5) has been expanded to allow specification of partial (K56.51) versus complete (K56.52) obstruction if known. The same descriptions were also applied to other and unspecified intestinal obstruction (K56.600–K56.609) and postprocedural intestinal obstruction (K91.30–K91.32).
Non-pressure skin ulcers (L97.- and L98.4-) can now be further specified to describe if there is muscle or bone involvement without necrosis or other specified severity by location. Many revisions happened in Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue to clarify code descriptions. New codes included M33.03, Juvenile dermatomyositis without myopathy, M33.13, Other dermatomyositis without myopathy, M33.93, Dermatopolymyositis, unspecified without myopathy, M48.061, Spinal stenosis, lumbar region without neurogenic claudication, and M48.062, Spinal stenosis, lumbar region with neurogenic claudication.
The location of an unspecified breast lump (N63) can now be described by laterality and quadrant or in the axillary tail and/or subareolar by laterality (N63.0-N63.42). Ectopic tubal or ovarian pregnancy is further specified as left, right, unspecified, and with or without intrauterine pregnancy in code subcategories O01.1 and O00.2. There are new codes for Maternal care for abnormalities of fetal heart rate or rhythm in the first trimester (O36.831-), second trimester (O36.832-), third trimester (O36.833-), or unspecified trimester (O36.839-).
Chapter 16, Certain Conditions Originating in the Perinatal Period added new codes for pulmonary hypertension of the newborn (P29.30) and other persistent fetal circulation (P29.38). Other specified perinatal digestive system disorders added Gestational alloimmune liver disease with code P78.84. Code P83.8, Other specified conditions of integument specific to newborn was expanded to P83.81, Umbilical granuloma and P83.88, Other specified conditions of integument specific to newborn. P91.8 has been expanded to create new codes for Neonatal encephalopathy in diseases classified elsewhere (P91.811) with instructions to “Code first the underlying condition if known.” P91.819 Neonatal encephalopathy, unspecified and P91.88, Other specified disturbances of cerebral status of newborn are also new codes.
There is a new code for acute respiratory distress (R06.03) and two new codes to describe unilateral or bilateral non-palpable testicle(s) (R39.83 and R39.84). Several descriptions have been added to the coma scale verbal response (R40.22-) and motor response (R40.23-) based on the patient’s age (two to five years or less than two years).
Code S06, Intracranial injury has a new note that 7th characters D and S do not apply to codes in category S06 with 6th character 7 (death due to brain injury prior to regaining consciousness) or 8 (death due to other cause prior to regaining consciousness). This change resulted in the loss of approximately 68 subsequent encounter and sequela codes. Unspecified multiple injuries (T07.-) and other and unspecified injury of unspecified body region (T14.8- and T14.9-) will now require the appropriate 7th character to be added for initial, subsequent, or sequela.
The Antenatal screening code (Z36) in Chapter 21 expanded to increase reporting options. Coding professionals will be able to report specific screening tests administered to pregnant patients, such as fetal growth retardation (Z36.4) and chromosomal abnormalities (Z36.0) with 17 new Z codes. There is a new code for Exercise counseling (Z71.82) and Nonprocreative genetic counseling (Z71.83). The risk for dental caries can now be described as low (Z91.841), moderate (Z91.842), high (Z91.843), or unspecified (Z91.849).
There were many more changes to the alphabetic index and Tabular List that indicate conditions that are included, result in different codes assigned, corrections to wording and punctuation, as well as coding note changes; be sure to carefully review the entire ICD-10-CM addenda to identify changes that will impact ICD-10-CM code assignment and/or sequencing.
ICD-10-CM Official Guidelines for Coding and Reporting FY 2018
Once again, FY 2018 also brought changes and additions to the official guidelines. Please refer to the FY 2018 Official Guidelines for Coding and Reporting on the CDC website to see all of the revisions. This article will discuss a few highlights.
This guideline added the word “in” to have the same meaning as “with.” This guideline was also expanded with the following added to where the FY 2017 guideline ended: “…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’).”
I.C.4.a.3) Diabetes mellitus and the use of insulin and oral hypoglycemics
This guideline was updated to indicate that “An additional code should be assigned from category Z79 to identify the long-term (current) use of insulin or oral hypoglycemic drugs.” Also, the guideline further clarifies that if the patient is treated with both oral medications and insulin, only code Z79.4 (long-term (current) use of insulin) should be assigned and that 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. This same clarification was also added to I.C.4.a.6) (a) for Secondary Diabetes mellitus.
I.C.5.b.1) In Remission
This guideline clarified that the appropriate codes for “in remission” are assigned based on provider documentation “unless otherwise instructed by the classification.” It goes on to state, “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.”
To help align with the code changes for blindness, this new guideline was added for FY 2018. “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.”
I.C.9.a.11) Pulmonary Hypertension
This is a new guideline for FY 2018. “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.”
I.C.9.e Acute myocardial infarction (AMI)
This section of the guidelines added clarification related to the types (1-5) of AMI and associated changes to the classification for FY 2018. Portions of the revisions state: “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.” Be sure to review this section of the guidelines closely to ensure accurate code assignment.
I.C.12.b Non-Pressure Chronic Ulcers
This section is a brand new guideline for FY 2018. I.C.12.b.1) clarifies that a code is not assigned if the documentation states that the non-pressure ulcer is completely healed on admission. I.C.12.b.2) states “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.”
I.C.12.b.3) indicates, “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.”
II.K Admissions/Encounters for Rehabilitation
This guideline clarifies the use of an injury code for admission/encounter 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,” according to the guidelines. For rehabilitation services following active treatment of an injury, the coding professional is instructed to “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.19.a for additional information about the use of 7th characters for injury codes.”
More Changes to Review Online
This article only touches upon some of the many FY 2018 ICD-10-CM addenda and ICD-10-CM Official Guidelines for Coding and Reporting additions and revisions. These changes impact visits and discharges beginning October 1, 2017 and should be reviewed in their entirety to help ensure specific and accurate code assignments that lead to quality data and compliant reimbursement.
For more information, review:
Karen M. Linder (Karen.Linder@rochesterregional.org) is coding director at Rochester Regional Health.
Linder, Karen M.
"FY 2018 Updates to ICD-10-CM"
Journal of AHIMA