Friday, August 26, 2016

ICD-10-CM 2017 Guideline Changes: Laterality, Coma and Stroke Scale, and Complications of Care

In the last edition of “In the kNOW”, the spotlight was on the ICD-10-CM guideline changes from Section I.A addressing conventions for the ICD-10-CM.  This included the expanded guideline concerning the term “with” and a new guideline on diagnosis code assignment and clinical criteria.  The next part of conventions, general coding guidelines, and chapter specific guidelines that will be reviewed will cover I.B (General Coding Guidelines).

The first guideline with an update in Section I.B is 13 which focuses on laterality.  Coders are instructed on the appropriate way to code bilateral conditions when that condition is treated in separate encounters.  This revised guideline states that the bilateral condition should be coded as such even during the first encounter to treat the condition, as at that time both side are still affected.  After treatment of one side which corrects the condition, only a unilateral code should be assigned for a second visit, since the condition is now only present on one side.  The exception to this is if the original treatment did not completely resolve the condition, then the bilateral code assignment would still be warranted.

Section I.B.14 presents the next guideline change and discusses the inclusion of the coma scale and NIH stroke scale (NIHSS) documentation.  This is the same guideline that provides information for BMI, pressure ulcer stages, and depth of non-pressure ulcers.  Under the revision, coders are instructed that they may take the documentation of the coma scale from an emergency medical technician, much as they might take the BMI from a dietitian.  There is a reminder that the diagnosis of acute stroke must be provided by the physician.  Further, coders are reminder that the diagnoses of coma scale and NIHSS-like BMI- may only be used as secondary diagnoses.

The final guideline change to Section I.B is to guideline 16 where documentation of complications of care is outlined.  A small change was made to the wording in this guideline which explains that the coding of a complication of care must be based on the physician’s documentation indicating a relationship between the condition and the care or procedure provided, unless otherwise instructed by the classification.  Those final words presented in bold are the revision to the guideline and simply allow coders to assign complications if directed by the classification system.

The next “In the kNOW” will begin to highlight changes under the chapter specific guidelines.   

This link will direct you to the CMS webpage for everything ICD-10-CM related:

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.

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