You’ve got less than a month before you must start using the 2023 ICD-10-CM codes, but just as importantly, Oct. 1 is also the deadline for you to start following the 2023 ICD-10-CM Guidelines, and you’ll find major updates to those rules hitting next month.
Here’s what they are: The ICD-10-CM Guidelines provide instructions for how to use the diagnosis codes. For instance, they offer guidance on which codes should be listed as the primary diagnosis, and how to select an accurate ICD-10-CM code. Much like the codes themselves, you’ll find updates to the guidelines that hit every year on October 1, and if you don’t get to know the changes, you could be submitting claims improperly. The penalty for that? Denied claims and lost reimbursement.
To help you select the right diagnosis code once the new rules hit, check out the following rundown of several pressing changes to the ICD-10-CM Guidelines for 2023.
New Guidelines Urge You to Query Providers
In some practices, it’s an unspoken rule that any confusion about the right diagnosis to report on a claim should be clarified with the provider. But until now, that guidance hasn’t been set in stone. The 2023 ICD-10-CM Guidelines put it in black and white this year, noting in section I.A.19 that the provider’s statement that a patient has a particular condition is sufficient, and you should base your code on that statement. “If there is conflicting medical record documentation, query the provider,” the new guidelines say.
In other words, if the provider documents that the patient has a particular condition, you’ve got the green light to code it. If the provider’s documentation makes it unclear whether the patient has one diagnosis vs. another, it’s your job to ask the clinician for clarity rather than trying to guess which code should be submitted on the claim.
Sequence Cancer Diagnoses Correctly
Another area of the ICD-10-CM Guidelines that has caused confusion in the past involves how to sequence the diagnosis codes when a patient has cancer. For instance, if you’re seeing a patient for chemotherapy, it’s unclear whether you should use the malignancy as the primary diagnosis or not. The 2023 ICD-10-CM Guidelines make this clearer.
“If the malignancy is chiefly responsible for occasioning the patient admission/encounter and treatment is directed at the primary site, designate the primary malignancy as the principal/first-listed diagnosis,” the guidelines note. However, the sole exception to that guideline involves administration of chemotherapy, immunotherapy or external beam radiation. If those treatments represent the chief reason for the encounter, “assign the appropriate Z51.– code as the first-listed or principal diagnosis, and the underlying diagnosis or problem for which the service is being performed as a secondary diagnosis,” the guidelines say.
In other words, if you saw a patient presenting for chemotherapy to treat cancer, you’d list Z51.11 (Encounter for antineoplastic chemotherapy) as the primary diagnosis, and the cancer itself as the secondary diagnosis.
Only Use Social Determinants of Health When Applicable
The ICD-10-CM manual includes social determinants of health (SDoH) codes to help you provide additional detail to payers beyond the actual ailments that patients are experiencing, but sometimes it can be hard to evaluate when these codes apply. The updated guidelines aim to clarify the issue, noting that you should only use the SDoH codes “when the documentation specifies that the patient has an associated problem or risk factor.”
For example, the guidelines state, there’s no reason to assign Z60.2 (Problems related to living alone) for every patient who lives alone. This code only applies if living alone presents a problem or risk factor for that patient.
Check Guideline Changes for Complications, Underdosing and More
In addition to the guideline changes noted above, the updates reflect dozens of other changes that will affect coders starting Oct. 1. Some highlights include:
- You should only report complications when they’re “clinically significant” (Section I.B.16).
- When cancerous lymphoid tissue spreads beyond the lymph nodes, use a code from C81-C85 with the final character “9” rather than a code for secondary neoplasm of the affected solid organ (Section I.C.2.t).
- Assign a code for patients on insulin that reflects whether they’re on oral or injectable insulin (or both) using the Z79 series (Sections I.C.4.a.3 and I.C.4.a.6.a).
- When reporting an underdosing code (T36-T50), you needn’t document a change in the patient’s condition. As long as you document that the patient is taking less of the medication than prescribed (or stopped taking it), then the code can be reported (Section I.C.19.e.5.c).
There’s much more to discover about the new ICD-10-CM code changes and guideline shifts that hit Oct. 1, 2023. To get a complete rundown of the updates, check out the online training session, Don’t Miss the Oct. 1 Deadline: New 2023 ICD-10-CM Codes, presented by Kim Huey MJ, CHC, CPC, CCS-P, PCS, CPCO. During the 60-minute training, you’ll find out which new codes are debuting, which are being deleted, and which guideline updates you must know to submit clean claims.
 |
Subscribe to Healthcare Practice Advisor |
| Get actionable advice to help improve your practice’s reimbursement, compliance, and success in this weekly eNewsletter. |
|
|
|