1. 2018 ICD-10-CM UPDATES
JULIE BOS, CPC, CPB, CPPM

2. AGENDA
OFFICIAL GUIDELINES
CHAPTER SPECIFIC
CHAPTERS 1-7

3. Section I Guideline Changes
Information has been added to clarify the meaning of ‘with (new text is bold)
The word ‘with’ or ‘in’ should be interpreted to mean ‘associated with’ or ‘due to’ when it appears in a code title, the Alphabeti Index, or an instructional note in the Tabular List
The 2018 Official Guidelines for Coding and Reporting includes a dozen substantive changes in Section I and one important change in Section II
Those changes are:
*presumes a casual relationship between the two conditions linked by these terms in Alpha/Tabular
*these conditions should be coded as related even in the absence of provider documentation explicitly linking them, UNLESS the documentation clearly states the conditions are unrelated,
*…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)
* For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented

4. Section I Guideline Changes
“CODE ALSO” guidelines are clarified.
When two codes may be required to fully describe a condition, a ‘code also’ note is indicated. The note does not provide sequencing direction. The new guidelines explain, “THE SEQUENCING DEPENDS ON THE CIRCUMSTANCES OF THE ENCOUNTER”

5. Section I Guideline Changes
Information is added for brachytherapy, within admissions/encounters involving chemotherapy, immunotherapy and radiation therapy
Admission solely for administration of the above:
Assign code Z51.0, Z51.11, or Z51.12 as the first listed or principal diagnosis code
If more than one of these therapies are done within the same encounter, more than one may be assigned in any sequence
The malignancy should be assigned as a secondary diagnosis
Z51.0 = Encounter for antineoplastic Radiation Therapy
Z51.11 – Encounter for antineoplastic Chemotherapy
Z51.12 – Encounter for antineoplastic Immunotherapy
However…IF the patient is being seen for the insertion or implantation of radioactive elements (brachytherapy), the appropriate malignancy code is sequenced first

6. Section I Guideline Changes
COMPLICATIONS OF RADIATION, CHEMO OR IMMUNOTHERAPY:
SEQUENCE Z51.0, Z51.11, OR Z FIRST
FOLLOWED BY COMPLICATION CODES
COMPLICATIONS FOR BRACHYTHERAPY
SEQUENCE THE MALIGNANCY FIRST FOLLOWED BY THE COMPLICATION

7. Section I Guideline Changes
DIABETES
Diabetes Mellitus and the use of insulin and oral hypoglycemics
E11-Type 2 diabetes
Z79 – long-term use of insulin or oral hypoglycemic drugs
Secondary diabetes mellitus
E08 – DM due to underlying conditon
E09 – Drug or chemical induced DM
E13 – Other specified DM
Underlying Condition must be sequenced first
Coding for diabetes with the use of insulin or oral diabetic medication is clarified:
*If the documentation in a medical record does not indicate the type of diabetes, but does indicate that the patient uses insulin, code E11-Type 2 Diabetes
An additional code from category Z79 should be assigned to indicate the long-term use of Insulin
Secondary DM: - ALWAYS caused by another condition or event (cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug, poisoning, etc.) and must have the underlying condition sequenced FIRST
If insulin used in treating Secondary DM – An additional code from category Z79 should be assigned to indicate the long-term use of Insulin – not to be assigned if insulin given temporarily

8. Section I Guideline Changes
MENTAL AND BEHAVIORAL DISORDERS
“In Remission”
Abuse vs Dependence
Mental and behavioral disorders due to psychoactive substance use (F10-F19) requires the provider’s clinical judgement. The appropriate codes for ‘in remission’ are assigned only on the basis of provider documentation, unless otherwise instructed by the classification
Abuse = mild substance use disorders
Dependence = moderate to severe use disorders

9. Section I Guideline Changes
‘BLINDNESS’ OR ‘LOW VISION’
Documented in both eyes, but visual impairment category not docmented
H54.3 – Unqualified visual loss, both eyes
H54.6 – Unqualified visual loss, one eye
H54.7 – Unspecified visual loss (no specification of one or both eyes)
New Guidelines for Blindness or low vision in both eyes documented when visual impairment category is not documented

10. Section I Guideline Changes
PULMONARY HYPERTENSION
I27 – OTHER PULMONARY HEART DISEASES
I27.1 – SECONDARY PULMONARY HYPERTENSION (KYPHOSCOLIOTIC H.D.)
I27.2 – OTHER SECONDARY PULMONARY HYPERTENSION
*BASE SEQUENCING ON THE REASON FOR THE ENCOUNTER*

11. Section I Guideline Changes
ACUTE MYOARDIAL INFARCTION (AMI)
REVISED GUIDELINES:
SPECIFY TYPE I AMI WHERE REQUIRED
OTHER GUIDELINES ADDED FOR OTHER TYPES OF MI
TYPE 1 ST elevation MI (STEMI)
CODES IDENTIFY THE SITE, SUCH AS ANTEROLATERAL WALL OR TRUE POSTERIOR WALL
SUBCATEGORIES I21.0-I21.2 = TYPE 1 ST elevation MI
NON-ST ELEVATION = I21.4 (NSTEMI)
OTHER UPDATED GUIDELINES FOR MI ICLUDE:
AMI documented as nontransmural or subendocardial but site provided
Subsequent acute myocardial infarction
See ‘Code also’ and ‘Code first’ notes related to complications and post-procedural MI’s following Cardiac Surgery

12. Section I Guideline Changes
NON-PRESSURE CHRONIC ULCERS
For admitted patients with non-pressure ulcers, do not assign a code if the documentation says the non-pressure ulcer is completely ‘healed’.
For admitted patients with non-pressure ulcers documented as ‘healing’, the new guidelines state:
Code based on documentation in record
If severity not provided, assign ‘unspecified’ severity
Unclear if ‘new’ or ‘healing’, query the provider
Present on admission, but healed at the time of discharge, code to documentation at time of admission

13. Section I Guideline Changes
RETAINED PRODUCTS OF CONCEPTION FOLLOWING A SPONTANEOUSW OR ELECTIVE TERMINATION OF PREGNANCY
SUBSEQUENT ENCOUNTERS
WITHOUT COMPLICATIONS = O03.4
INCOMPLETE SPONTANEOUS W/O COMPLICATONS = O07.4
SPECIFIC COMPLICATION: - ASSIGN O03 OR O07 APPROPRIATE COMPLICATION INSTEAD OF O03.4, OR O07.4

14. Section I Guideline Changes
CODING OF PATHOLOGIC FRACTURES
LANGUAGE ADDE TO CLARIFY ‘ACTIVE TREATMENT’
NEW LANGUAGE = 7TH CHARACTER ‘D’ IS REPORTED FOR ENCOUNTERS AFTER THE PATIENT HAS COMPLETED ACTIVE TREATMENT (Routine care for the fracture during the healing and recovery phase)
USE OTHER 7TH CHARACTERS AS APPROPRIATE FOR HEALING PROBLEMS SUCH AS MALUNIONS, NONUNIONS, SEQUELAE
GUIDELINES FOR FUNCTIONAL QUADRIPLEGIS ARE DELETED,
EFFECTIVE 10/1/2017

15. Section II Guideline Changes
ADMISSIONS/ENCOUNTERS FOR REHABILITATION
SEQUENCE FIRST THE CONDITION FOR THE SERVICE PERFORMED
IF THE CONDITION IS NO LONGER PRESENT:
REPORT THE APPROPRIATE AFTERCARE CODE AS THE FIRST LISTED/PRINCIPAL DIAGNOSES
AFTER CARE FOLLOWING AN INJURY
ASSIGN THE INJURY CODE WITH THE APPROPRIATE 7TH CHARATER FOR SUBSEQUENT ENCONTER

16. 2018 CODE CHANGES CHAPTERS 1-7
BRIEF OVERVIEW – REVIEW NOTATIONS IN CURRENT ICD-10-CM CODING BOOKS

17. CHAPTERS 1-3
CHAPTER ONE: CERTAIN INFECTIOUS AND PARASITIC DISEASES (A00-A09)
TWO CODES ADDED UNDRE A04.7
CHAPTER TWO: NEOPLASMS (C00-D49)
NOTE REVISIONS; INCLUSION AND EXCLUSION REVISIONS
NEW CODES UNDER SUBCATEGORY C96.2
C96.20; C96.21, C96.22, C96.29
CHAPTER THREE: DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS AND CERTAIN DISORDERS INVOLVING THE IMMUNE MECHANISM (D50-D89)
ADDED AND DELETED LANGUAGE IN D63.0 & D64.81
ADDED, DELETED AND REVISED EXCLUDES NOTES UNDER D89.4

18. CHAPTERS 4-5
CHAPTER FOUR: ENDOCRINE NUTRITIONAL AND METABOLIC DISEASES (E00-E89
NEW DM CODES:
E11.1,, E11.10, E11.11
NEW METABOLIC DISORDER CODES:
E85.81, E85.82, E85.89
WATCH FOR REVISIONS, ADDITIONS AND DELETIONS IN INCLUDES/EXCLUES NOTES
CHAPTER FIVE: MENTAL BEHAVIORAL AND NEURODEVELOPMENTAL DISORDERS (F01-F99
ADDED NEW INCLUSION TERMS UNDER SEVERAL CODES
NEW CODES: F10.11; F11.11; F12.11; F13.11; F14.11; F15.11; F16.11; F18.11; F19.11; F50.82

19. CHAPTERS 6-7 CHAPTER SIX: DISEASES OF THE NERVOUS SYSTEM (G00-G99)
WATCH EXLUDES1 NOTES AND ADDITIONAL LANGUAGE
NEW CODES: G12.23; G12.24; G12.25
DISEASES OF THE EYE AND ADNEXA (H00-H59)
MANY NEW CODES TO INCREASE SPECIFICITY
WATCH NEW ‘CODE FIRST’ GUIDELINES
NEW CODES FOR H44.2
H44.2A; H44.2B, H44.2C; H44.2D; H44.2E