Pediatric Coding Alert

And learn how to use new code Z71.85 safely.

The Centers for Disease Control and Prevention (CDC) has only made a small number of changes to the ICD-10 coding guidelines for 2022. But those changes, which took effect on Oct. 1, 2021, are significant.

Here are the three big takeaways you’ll want to understand to keep your coding on track, along with opinions from some of our coding experts.

1. Code COVID Follow-Ups, History Correctly With These New Instructions

Since the COVID-19 pandemic began, the CDC has added a number of new codes along with instructions about how to code for exposure and confirmed cases and sequencing guidelines for associated manifestations, signs, and symptoms. The CDC has expanded these instructions in ICD-10 2022 to clarify the way you should code for sequela of COVID-19, for a new case of COVID-19 in a patient who had previously been affected by the condition, and for follow-up visits after the patient’s COVID-19 condition has resolved.

For sequela of COVID-19 or “associated symptoms or conditions that develop following a previous COVID-19 infection,” you’ll use new code U09.9 (Post COVID-19 condition, unspecified) along with a “code(s) for the specific symptom(s) or condition(s) related to the previous COVID-19 infection, if known.”

For a new case of COVID-19 in a patient who had previously been affected by the condition you’ll use U09.9 with U07.1 (COVID-19) along with “code(s) for the specific condition(s) associated with the previous COVID-19 infection and code(s) for manifestation(s) of the new active (current) COVID-19 infection.”

For follow-up evaluations after the patient’s COVID-19 condition has resolved you’ll use Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) and Z86.16 (Personal history of COVID-19) providing the patient is “without residual symptom(s) or condition(s) … and COVID-19 test results are negative.”

2. Code Laterality, SDoH, and Blood Alcohol Without Provider Documentation

ICD-10 2022 also sees a big change in guideline 1.B.14, the guideline that gives coders permission to assign codes based on information in the patient’s medical record recorded by clinicians other than the patient’s provider, which the guidelines define as the “physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis.”

Thanks to the revision, and a change to guideline 1.B.13, you will now be able to code the following “based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis)”:

• Body mass index (BMI)
• Depth of non-pressure chronic ulcers
• Pressure ulcer stage
• Coma scale
• NIH stroke scale (NIHSS)
• Social determinants of health (SDOH)
• Laterality
• Blood alcohol level

The change is “a reasonable allowance when laterality can be reasonably related, which will help to reduce the unspecified coding problem,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/ coding coordinator at County of Stanislaus Health Services Agency in Modesto, California. But before you begin to infer laterality, or any of the other items on the list, make sure you understand the following caveats:

i. The guideline notes you may have to assign an unspecified code when “documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification.”

ii. The guideline also cautions that “if there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.”

iii. The guideline also clarifies that “the BMI, coma scale, NIHSS, blood alcohol level codes, and codes for social determinants of health should only be reported as secondary diagnoses.”

iv. And lastly, “the patient’s provider must document any associated diagnosis, such as overweight, obesity, acute stroke, or pressure ulcer” says Leah Fuller, senior consultant, Pinnacle Enterprise Risk Consulting Services LLC, in Centennial, Colorado.

3. Code Z71.85 Correctly

In Pediatric Coding Alert Volume 24, Number 9, we told you about a new code: Z71.85 (Encounter for immunization safety counseling). Now, in addition to the instruction that you should code also an encounter for immunization (Z23) or immunization not carried out (Z28.-) as applicable, and that you should obey the Excludes1 note that tells you to use Z71.84 (Encounter for health counseling related to travel) instead if your provider’s immunization safety counseling is travel-related, an addition to guideline I.C.21.c.10 provides additional insight into the kind of counseling that should be documented. It tells you that the code “should not be used for the provision of general information regarding risks and potential side effects during routine encounters for the administration of vaccines,” but for “counseling of the patient or caregiver regarding the safety of a vaccine.”

You can find the updated 2022 ICD-10 Guidelines by going to ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2022/10cmguidelines-FY2022-7-2022-7-15-21-update-508.pdf.