Featured coffee – Rolo Frappuccino
We’re finishing our review of the 2022 ICD-10-CM Official Guidelines for Coding and Reporting changes in C. Chapter-Specific Coding Guidelines.
Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)
a. General Rules for Obstetric Cases
3) Final character for trimester
Before 2022, guidance was provided that when there was an “in childbirth” option for the obstetric complication when delivery occurs, the “in childbirth” code should be assigned.
Effective for 2022, when the ICD-10-CM classification does not provide an obstetric code that includes an “in childbirth” option, we assign the ICD-10-CM code that describes the current trimester.
a. Alcohol, tobacco, and drugs use during pregnancy, childbirth, and the puerperium
1) Alcohol use during pregnancy, childbirth, and the puerperium
3) Drug use during pregnancy, childbirth, and the puerperium
The only change for 2022 is the word “mother” has been changed to “patient.”
p. Code O94, Sequelae of complication of pregnancy, childbirth, and the puerperium
1) Code O94
Added “sequela or.”
Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
ICD-10-CM code R40.20 – Unspecified coma may be assigned in conjunction with codes for any medical condition.
Another important note: “If multiple coma scores are captured within the first 24 hours after hospital admission, assign only the code for the score at the time of admission. ICD-10-CM does not classify coma scores that are reported after admission but less than 24 hours later.”
Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)
d. Coding of Burns and Corrosions
6) Burns and corrosions classified according to extent of body surface involved
Codes from category T31 or T32 should be assigned “for acute burns or corrosions when the site of the burn or corrosion is not specified or when there is a need for additional data.”
“Codes from categories T31 and T32 should not be reported for sequelae of burns or corrosions.”
Chapter 21: Factors influencing health status and contact with health services (Z00-Z99)
b. Z Codes Indicate a Reason for an Encounter or Provide Additional Information about a Patient Encounter
4) History (of)
This clarification caused me to do a happy dance! “The reason for the encounter (for example, screening or counseling) should be sequenced first and the appropriate personal and/or family history code(s) should be assigned as additional diagnos(es).”
10) Counseling
New ICD-10-CM code Z71.85 – “Encounter for immunization safety counseling, is to be used for counseling of the patient or caregiver regarding the safety of a vaccine. This 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.”
17) Social Determinants of Health (New section)
“coding professionals may utilize documentation of social information from social workers, community health workers, case managers, or nurses, if their documentation is included in the official medical record.”
Chapter 22: Codes for Special Purposes (U00-U85)
For the new ICD-10-CM code U09.9, the guidelines instruct us to see Section I.C.1.g.1.m.
Coffee With a Medical Coding Auditor 