ICD-10-CM 2017 Guideline Changes: Abnormal Findings, Present on Admission Findings

"In the kNOW" has been presenting a review of the ICD-10 Coding Guidelines and this edition is focusing on ICD-10-CM changes in Section II, Section III, Section IV, and Appendix A.   

The only changes to Section II: Selection of Principal Diagnosis and Section III: Reporting Additional Diagnoses guidelines is the addition in paragraph three of the sentence that instructs coders that the Uniform Hospital Discharge Data Set (UHDDS) definitions are applicable to all levels of hospice care in addition to acute care, short term, long term, psychiatric hospitals, home health agencies, rehab facilities, nursing homes, etc. 

Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services presents an addition in the first paragraph which states that the guidelines in Section I are applicable to outpatient services including office visits.  There is also an addition to the variations between inpatient and outpatient coding guidelines which states for hospital-based outpatient services and provider-based office visits, the UHDDS definition of principal diagnosis is not applicable.  The final change to Section IV is under P. Encounters for general medical examinations with abnormal findings.  Here the definition of abnormal findings is clarified by stating the meaning is identification of a new condition or diagnosis or the worsening of a chronic condition.  The coding direction remains the same, with assignment of the code for general medical exam with an abnormal finding coded first and an additional code assigned for the specific abnormal finding.

Appendix I which addresses Present on Admission Reporting Guidelines has a few updates.  The first addition is the identification of the CDC website locating all ICD-10-CM codes where Present on Admission (POA) indicator assignment is not necessary.  The codes that are exempt from POA assignment are either always present on admission, or are not considered a current disease or injury.  Two other clarifications to POA guidelines were made.  Under Acute and Chronic Conditions, clarification was added stating that the guideline for codes that contain multiple clinical concepts should be used if one code identifies both an acute and chronic condition.  An additional paragraph was then added to Codes that Contain Multiple Clinical Concepts indicating that the POA assignment “Y” should be entered if all the concepts included in a code were present on admission.  Previous information stating that POA indicator “N” was to be used if even one concept in a multiple concept code was not present on admission still stands.  

This concludes our review of the ICD-10 guideline changes for 2017.  The next posting of “In the kNOW” will look a major CPT coding change for moderate (conscious) sedation upcoming 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.