ICD-10-CM 2017 Guideline Changes: Newborns, Coma Scale, 7th Character, and More!

This issue of “In the kNOW” contains a review of the final Chapter-Specific Coding Guidelines of Section I.C which are applicable to all healthcare settings. 
 
We begin by examining Chapter 16 where there is new guidance at I.C.16.b.1 for observation and evaluation of newborns for suspected conditions not found.  When a healthy infant is evaluated or observed for a suspected condition which is ruled out, coders should assign a code from the Z05 category.  When signs or symptoms of a condition are present, then the signs or symptoms should be coded instead of the Z05 category code.  I.C.16.b.2 states that coders can use the Z05 category code as a principal diagnosis when Z38 codes are not appropriate, such as for readmissions.  I.C.16.b.3 tells coders that Z05 category codes are permitted to be used on the birth record, but only as a secondary diagnosis after the appropriate Z38 code for place of birth and type of delivery is entered as the principal diagnosis.
 
Chapter 18 that covers symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified first revised the coma scale at I.C.18.e.  Here coders are directed that the coma scale can be used in for assessing the central nervous system regardless of the medical condition.  This means that it is applicable for non-trauma conditions.  Also, in Chapter 18 at I.C.18.i, there is discussion of the usage of the NIH stroke scale code.  This code may be used in conjunction with an acute stroke code but should be sequenced secondarily.  Multiple scores may be assigned based on facility protocol, but at a minimum the initial score should be recorded.  Section I.B.14 is referenced for the documentation that is acceptable for assigning this code.

Several revisions occur in Chapter 19 (Injury, poisoning, and certain other consequences of external causes).  The first is I.C.19a where the 3rd and 4th paragraphs discuss the use of the 7th characters “A” and “D”.  The 3rd paragraph clarifies that the “A” 7th character is used for each encounter where the patient is receiving active treatment.  The 4th paragraph states that the “D” 7th character is used when the patient has completed active treatment and is in the healing or recovery phase and receiving routine care.  I.C.19.c.1 has two revisions for initial vs. subsequent encounter for fractures.  The first states that the 7th character for initial encounter is used for each encounter where the patient is receiving active treatment for the fracture.  Also addressed are the 7th character for open fractures of the femur, lower leg (including the ankle) and the forearm which are based on the Gustilo classification.  When the Gustilo classification is not provided for an open fracture, the 7th character assigned should be for Type I or Type II.  Adverse effects, poisoning, underdosing, and toxic effects have a guideline update at I.C.19.e.5.b poisoning.  Here coders are instructed that if the intent of a poisoning is unknown or unspecified, it is to be coded to accidental.  Undetermined intent is only to be used when documentation states the cause cannot be determined.  The last revisions in Chapter 19 occur at I.C.19.f (Adult and child abuse, neglect, and other maltreatment).  The first change expands the code section referenced in paragraph 3 to (X92-Y09).  The other change is the distinction of codes Z04.41 adult rape, and Z04.42 child rape.  

The final chapter-specific guidelines are for Factors Influencing Health Status and Contact with Health Services (Chapter 21).  I.C.21.c.3 is for status codes and there are several changes including the addition of Z19 for hormone sensitivity malignancy status.  Additionally, a note was added at Z68 stating that the assignment of the code for BMI is only to be used when it meets the definition of reportable diagnosis.  Changes were made at I.C.21.c.6 for observation including the insertion of the word “three” when indicating the observation code categories.  Also, mention is made that the observation codes are to be listed as the principal diagnosis only, with the only exception when the Z05 code for observation of a suspected condition for a newborn is ruled out on the infant’s birth record.  In that instance, a code from the Z38 category will be sequenced first followed by the Z05 category code.  At I.C.21.c.7 (aftercare), Z51 was expanded to encounter for other aftercare and medical care.  Encounters for Obstetrical and Reproductive Services (I.C.21.c.11) states that Z3A codes identifying the weeks of gestation are not to be assigned with abortive outcomes, elective termination of pregnancy, or postpartum conditions.  Under Miscellaneous Z-codes (I.C.21.c.14), specifically Prophylactic Organ Removal a new code was added – Z29 encounter for other prophylactic measures.  In the same section, a note was added to Z72 – problems related to lifestyle, that this code is assigned only when documentation specifically states that the patient has an associated problem.  

The next posting of “In the kNOW” will look at the remainder of the guideline changes for ICD-10-CM for 2017.

This link will direct you to the CMS webpage for everything ICD-10-CM related:
https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.