By Laurie M. Johnson, MS, RHIA, FAHIMA
Since the implementation of ICD-10-CM/PCS in October 2015, the periodic coding updates have included many changes. For FY 2019, the diagnosis update includes a more manageable number: 279 new codes, 143 revised codes, and 51 deleted codes. This article is an overview of the major changes in ICD-10-CM with a focus on the FY 2019 Guidelines for Coding and Reporting update.
All of the changes and updates can be found in the addenda documents that have been published on the Centers for Medicare and Medicaid Services (CMS) website. The items underlined in guidelines have been moved within the guidelines since FY 2018, the narrative changes are bolded, and italics are used to indicate revisions to headings.
Updates to the ICD-10-CM Guidelines
Guideline I.B.14, Documentation by Clinicians Other than the Patient’s Provider, has been updated so the coding professional may use clinical documentation by others to code the social determinants of health, which fall in the category range of Z55 – Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances). These codes have been added because they represent social data, not medical data.
Guideline I.B.19, Coding for Healthcare Encounters in Hurricane Aftermath, was added to capture injuries and poisonings that are related to a hurricane. The guideline states that an external cause of morbidity code should not be assigned if there is not any injury, adverse effect, or poisoning. The sequencing of these external cause codes should be the cataclysmic event (X37.0-, Hurricane) first, followed by other external cause of injury codes. For injuries that are not a direct result of the hurricane, do not assign X37.0-. The guidelines also encourage the coding professional to assign Z codes to fully explain the healthcare encounter or transfers between healthcare facilities.
Additional language has been added to I.C.1.d.5, Sepsis due to a postprocedural infection. The updated guideline indicates that for infections following a procedure, a code from T81.40 – T81.43 or O86.00 – O86.03 should be reported first. If the patient has postprocedural septic shock, then the codes from T81.40 – T81.43 or O86.00 – O86.03 should be assigned with T81.12-, Postprocedural septic shock. T81.12- will replace the reporting of R65.21. Codes for any acute organ dysfunction should also be assigned. For infections following infusion, transfusion, therapeutic injection, or immunization, a code from subcategory T80.2- or subcategory T88.0- should be reported first. Again, if the patient has severe sepsis, then a code from R65.2- should be assigned with any acute organ dysfunction codes.
Guideline I.C.2.m, Current malignancy versus personal history of malignancy, has been updated to specify that codes in the range of Z85.0 – Z85.7 are used to capture history of primary malignancy, not secondary malignancies. A code from subcategory Z85.8- may be assigned for history of primary or secondary malignancies.
A new guideline, I.C.5.c., was added to the Mental and Behavioral Health Chapter. This guideline, Factitious Disorder, includes Munchausen’s Syndrome. A code from subcategory F68.1- is used to capture this condition. If the disorder is by proxy, then the perpetrator should be assigned the code F68.A. The victim will be assigned a code from category T74 (Adult and child abuse, confirmed) or T76 (Adult or child abuse, suspected).
The Circulatory System has had the inclusion codes updated for hypertension with heart involvement. Guidelines I.C.9.a.1 and I.C.9.a.2 also state that the conditions should be coded separately if the provider documents that there is no relationship between hypertension and heart and/or kidney involvement. Another change to this chapter is for Guideline I.C.9.e.4, Subsequent acute myocardial infarctions. If a subsequent acute myocardial infarction of one type occurs within four weeks of the initial myocardial infarction of a different type, assign the appropriate code from I21 to identify each type. Do not assign the code from I22 (subsequent), which is reserved for when the initial and subsequent myocardial infarctions are type 1 or unspecified.
A new guideline has been added to Chapter 15: I.C.15.l.3, Pregnancy, Childbirth, and the Puerperium, which addresses drug use. Assign a code from subcategory O99.32- when the mother uses drugs during pregnancy or puerperium. The drug use includes illegal drugs or inappropriate use/abuse of prescription drugs. Secondary codes can be added from F11 – F16 and F18 – F19 for the manifestations of drug use.
Guideline I.C.18.e in Chapter 18 (Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, NEC) has been revised to indicate that the individual or total Glasgow coma scale should not be reported for patients with a medically induced coma or a sedated patient.
The 2019 version of Chapter 19 guideline I.C.19.e.5(c) includes an example of underdosing, which states “discontinuing the use of a prescribed medication on the patient’s own initiative (not directed by the patient’s provider) is also classified as an underdosing.” The code Z91.14- was also added to the codes for noncompliance. There is also a recommendation in I.C.19.f. to assign Z04.81 for patients who are suspected cases of forced sexual exploitation or forced labor exploitation that is ruled out during the encounter. The encounter for examination and observation of a victim following forced sexual exploitation should be assigned Z04.82, not T76.
Additional updates for Chapter 21 (Z codes) include the guidance that Body Mass Index (BMI) should not be reported for pregnant patients. BMI is only reported when an associated diagnosis is reported such as overweight or obesity. There were no changes in the Z code principal/first-listed only codes.
Section II (Selection of Principal Diagnosis), Section III (Reporting Additional Diagnoses), and Appendix I did not have any changes for FY 2019. There are 120 pages in this version of the guidelines.
Updates to the Tabular Volume
Overall, the Tabular has been updated for errors in spelling and punctuation. There were no code changes in Chapters 1, 3, 8, 10, and 12.
There were codes added for neoplasms of the upper and lower eyelids including laterality in Chapter 2, Neoplasms. In Chapter 4, Endocrine, Nutritional, and Metabolic Diseases, additions were made for disorders of amino-acid metabolism (E72.81 – E78.89), sulfatase deficiency (E75.26), elevated lipoprotein (a) (E78.41), other hyperlipidemia (E78.49), and plasminogen deficiency (E88.02). Chapter 5, Mental, Behavioral, and Neurodevelopmental Disorders, added codes for cannabis dependence and use with withdrawal (F12.23, F12.93), postpartum depression (F53.0) and puerperal psychosis (F53.1), and factitious disorder imposed on another meaning by proxy (F68.A). Codes were added for anatomical clonic hemifacial spasm (G51.31 – G51.39) and specificity for muscular dystrophy (G71.00 – G71.09). The clonic hemifacial spasms are involuntary contractions of the facial muscles and are almost always unilateral. The underlying cause could be compression of a facial nerve. The muscular dystrophy codes now include an unspecified as well as Duchenne, facioscapulohumeral, and other specified muscular dystrophies.
Chapter 7, Diseases of Eye and Adnexa, has new codes for upper and lower eyelids as well as laterality throughout the chapter. Brow ptosis has been expanded to include laterality (H57.811 – H57-819). Chapter 9, Diseases of the Circulatory System, has new codes for cerebral infarctions due to occlusion or stenosis of small artery or other cerebral infarction (I63.81 – I63.89). New codes were added for hereditary cerebrovascular diseases such as cerebral autosomal dominant artery with subcortical infarcts and leukoencephalopathy (CADASIL) (I67.850 – I67.858). CADASIL is the most frequent form of hereditary stroke disorder and can be caused by mutations in a gene on chromosome 19. Chapter 11, Diseases of the Digestive System, expanded acute appendicitis (K35.-) to include localized or generalized peritonitis, with or without gangrene or perforation, with or without abscess. Ischiorectal abscess has been expanded to specify horseshoe or other (K61.31 – K61.39). Cholecystitis (K81) and cholelithiasis (K80) have added instructional notes to also assign K82.A2 for associated perforation of gallbladder or K82.A1 for associated gangrene of the gallbladder, which are also new codes. Myalgia in Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue, has been expanded to unspecified site, mastication muscle, auxiliary muscles of head/neck, and other site (M79.10 – M79.18). Chapter 14, Diseases of the Genitourinary System, has new codes for urethral stricture (N35.-) predominantly for the male gender. The expansion includes codes for post-traumatic of overlapping sites, postinfective of overlapping sites, other urethral stricture, and unspecified. The other urethral stricture includes meatal, bulbous, membranous, anterior, overlapping sites, and unspecified site. There are two new codes for female gender including other urethral stricture (N35.82) and unspecified urethral stricture (N35.92). For Chapter 15, new codes were added for triplet pregnancy with trichorionic/triamniotic (O30.1-) and quadruplet pregnancy with quadchorionic/quadamniotic (O30.2-) and other specified multiple gestation (O30.8-). Each of these subcategories include first, second, third, and unspecified trimester. There is also an expansion of Infection of obstetric surgical wound to include the level of infection (O86.00 – O86.09).
For Chapter 16, Certain Conditions Originating in the Perinatal Period, new codes for newborns affected by maternal drug use (P04.11 – P04.19) are listed, which includes the drug class. Additions have been made for fetal inflammatory response syndrome (FIRS – P02.70) and newborn affected by other conditions from chorioamnionitis (P02.78). New codes have been added for maternal use of drugs of addiction including unspecified, hallucinogens, cannabis, and other maternal noxious substances (P04.40, P04.42, P04.81, P04.89). A code has been added for congenital Zika virus disease (P35.4). This code is appropriate when a mother is infected by the Zika virus and the baby is affected when born. There are new codes for transitory endocrine and metabolic disorders specific to newborns including hypernatremia (P74.21), hyponatremia (P74.22), hyperkalemia (P74.31), hypokalemia (P74.32), alkalosis of newborn (P74.41), hyperchloremia (P74.421), hypochloremia (P74.422), and other transitory electrolyte disturbance of newborn (P74.49). Chapter 17, Congenital Malformations, Deformations and Chromosomal Abnormalities, has new codes for doubling of uterus including unspecified, complete septate, partial septate, and other specified (Q51.20 – Q51.28). There are new codes for Angelman syndrome (Q93.51), other deletions of part of a chromosome (Q93.59), and Williams Syndrome (Q93.82). According to the National Library of Medicine, Angelman syndrome is a complex genetic disorder which primarily affects the nervous system and has characteristics of delayed development, intellectual disability, severe speech impairment, and ataxia. Other characteristics are epilepsy and microcephaly. Chapter 18, Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, has additional codes for other abnormal findings in urine including hypocitraturia, hyperoxaluria, hyperuricosuria, hypercalciuria, and other (R82.991 – R82.998). Hypocitraturia is excretion of less than 320 mg of citrate per day, which may be an indicator for the development of kidney stones. Hyperoxaluria is the excessive excretion of oxalate, which is also an indication for the development of kidney stones. Hyperuricosuria (HUU) means that there is an excessive amount of uric acid in the urine. The threshold for men is 800 mg/day and for women is 750 mg/day. Hypercalciuria is excessive excretion of urinary calcium, which is another cause of calcium kidney stone disease. The threshold for men is 300 mg/day and for women 250 mg/day. New codes for abnormal radiologic findings on diagnostic imaging of testis including laterality (R93.811 – R93.89) were also created.
Chapter 19, Injury, Poisoning and Certain Other Consequences of External Causes, has the addition of poisoning by ecstasy (T43.64-). New codes have been added for forced adult/child sexual and labor exploitation that has been confirmed or suspected (T74.51-, T74.52-, T74.61-, T74.62-, T76.51-, T76.52-, T76.61-, T76.62-). Subcategory T81.4- has been expanded to include codes T81.40 – T81.49 for different situations of infection following a procedure such as deep incisional surgical site, abscess, sepsis, other, and unspecified. For Chapter 20, External Causes of Morbidity, one new code was added for multiple perpetrators of maltreatment and neglect (Y07.6).
Chapter 21, Factors Influencing Health Status and Contact with Health Services, has a new block which is identified at the beginning of the chapter listed as Z19 Hormone sensitivity malignancy status. New Z codes have been added for an encounter for examination and observation of a victim following forced sexual or labor exploitation (Z04.81 – Z04.89). A code was also added to capture personal history of forced labor or sexual exploitation in childhood (Z62.813) or adulthood (Z91.42). Please note that the adult is not clearly stated but does appear indexed using the descriptor of adult. Screening for mental health disorders including depression, maternal depression, other mental health and behavioral disorders, and unspecified have new codes assigned to capture these services (Z13.30 – Z13.39). There are new codes for screening for developmental disorders in childhood including unspecified developmental delays, autism screening, global developmental delays (milestones), and other developmental delays (Z13.40 – Z13.49). Z20.821 has been added for contact with Zika and suspected Zika virus exposure.
Last year, there was a problem regarding the availability of vaccines, so code Z28.82 was created for FY 2019 for immunizations not carried out due to unavailability of a vaccine. This code encompasses delay in vaccine delivery, manufacturer delays, and lack of availability. Codes were added to capture family history of elevated lipoprotein (a) (Z83.430) or other disorder of lipoprotein metabolism and other lipidemia (Z83.438).
Updates to the Index Volume
Punctuation and spelling error corrections dominate the changes of the Index along with the addition of the new code entries. The specific values of the coma score for motor, opening of eyes, and verbal response have been added. There were minimal changes to the External Cause Index. The one notable change is an update in the code for Place of Occurrence of road from Y92.488 to Y92.410.
Updates to the Table of Drugs and Chemicals, Table of Neoplasms
There were two revisions in the Table of Drugs and Chemicals. These changes were updates to the codes for the substances MDMA, which is also listed as methylenedioxymethamphetamine. The codes were revised from T43.621 to T43.641 (poisoning); T43.622 to T43.642 (self-harm); and T43.623 to T43.643 (assault). T43.625 for adverse effect was deleted, and the underdosing code T43.626 was deleted.
The Table of Neoplasms had the addition of sebaceous cell under different anatomic sites of the eye which include the canthus, eyelid, lid, meibomian gland, palpebra, and skin. Codes have been added for malignant primary, malignant secondary, Ca in situ, Benign, Uncertain Behavior, and Unspecified Behavior.
Updates Low in Number, High in Importance
The updates to the ICD-10-CM codes are greatly reduced from the previous few years. Many of the revisions include updates to punctuation and spelling. The changes to the Index, Table of Drugs and Chemicals, Neoplasm Table, and External Cause Table are primarily due to the new codes, spelling, and punctuation corrections. It is important to review these resources and consider how the updates will affect your hospital-specific coding guidelines or data collected by your facility.
For updates to the Tabular Volume, see the expanded online-only version of this Coding Notes article in AHIMA’s HIM Body of Knowledge at http://bok.ahima.org.
Centers for Disease Control and Prevention. ICD-10-CM Official Guidelines for Coding and Reporting FY 2019. www.cdc.gov/nchs/icd/data/10cmguidelines-FY2019-final.pdf.
Centers for Disease Control and Prevention. International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM). July 26, 2018. www.cdc.gov/nchs/icd/icd10cm.htm.
Centers for Medicare and Medicaid Services. 2019 ICD-10-CM. August 27, 2018. www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-CM.html.
Laurie M. Johnson (email@example.com) is senior healthcare consultant at Revenue Cycle Solutions, LLC.
Johnson, Laurie M. “FY 2019 ICD-10-CM Updates: Getting Back to Normal.” Journal of AHIMA 89, no. 10 (November-December 2018): 52–53