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New ICD-10-CM guidelines revise COVID-19 instructions, advise on social factors

Coders and medical practice staff can get a head start on a series of updated rules for diagnosis coding – the 2021 version of the ICD-10-CM Official Guidelines on Coding and Reporting was issued today – weeks ahead of the typical early August release date.
The coding guidelines, which take effect Oct. 1, include additional instructions on reporting manifestations of COVID-19 (U07.1), as well as new guidance on social determinants of health and acute kidney failure, among other changes.
A new section added for COVID-19 expands on the temporary coding guidelines posted in April by the ICD-10-CM Coordination and Maintenance Committee. Note that those temporary guidelines are set to expire Sept. 30.
Among the additions: New instructions for “Acute respiratory manifestations of COVID-19” that instruct: “When the reason for the encounter/admission is a respiratory manifestation of COVID-19, assign code U07.1, COVID-19, as the principal/first-listed diagnosis and assign code(s) for the respiratory manifestation(s) as additional diagnoses.”
Acute respiratory failure (J96.0-) has been added as another acute respiratory manifestation that may be coded secondary to U07.1. 
The 2021 guidelines also include a new subsection on non-respiratory manifestations of COVID-19, instructing that “when the reason for the encounter/admission is a non-respiratory manifestation (e.g., viral enteritis) of COVID-19, assign code U07.1, COVID-19, as the principal/first-listed diagnosis and assign code(s) for the manifestation(s) as additional diagnoses.”
A section on coding “presumptive positive” COVID-19 cases was not included in the 2021 guidelines because it refers to cases awaiting a second, confirmatory CDC lab test – a practice that is no longer required.
In other changes:
  • The guidelines clarify that social determinants of health may be coded if self-reported by patients, “as long as the patient self-reported information is signed off by and incorporated into the health record by either a clinician or provider.” Social determinants of health, found in code categories Z55-Z65, report potential health hazards related to socioeconomic and psychosocial circumstances that may complicate the care of the patient (e.g., the patient is unemployed).
  • You have new coding instructions to follow for diabetic patients treated with insulin, oral hypoglycemics and injectable non-insulin drugs. For example, if the patient is taking both insulin and an injectable non-insulin antidiabetic drug, assign both Z79.4 (Long term [current] use of insulin) and Z79.899 (Other long term [current] drug therapy). If the patient is taking oral hypoglycemic drugs and an injectable non-insulin antidiabetic drug, assign code Z79.84 (Long term [current] use of oral hypoglycemic drugs) in addition to code Z79.899.
  • A new hypertension guideline in Diseases of the Circulatory System (I00-I99) states that when a patient has hypertensive chronic kidney disease and acute renal failure, you should code both conditions and sequence the codes based on the reason for the encounter.
  • The CDC made significant edits to the coding guidelines for vaping-related disorders that it released Oct. 17, 2019. The final version, which you’ll find in Diseases of the Respiratory System (J00-J99), U07.0, instructs you to code U07.0 as the principal diagnosis when the patient presents with conditions related to vaping, including lung injury due to vaping. You should report additional manifestation codes, such as acute respiratory failure (J96.0-) with lung injury, but you should not report other associated respiratory signs and symptoms such as shortness of breath. “However, it would be appropriate to code separately any gastrointestinal symptoms, such as diarrhea and abdominal pain,” the guidelines state.
  • New language for the puerperal sepsis section of Pregnancy, Childbirth, and the Puerperium (O00-O9A) warns coders that they should not report O85 for sepsis that follows and obstetrical procedure. A note points them to the Sepsis due to a postprocedural infection of Chapter 1 Certain Infectious and Parasitic Diseases (A00-B99), U07.1.
  • Take note of additional guidance under the COVID-19 infection in pregnancy, childbirth and the puerperium section in chapter 15. The first paragraph, which instructs coders to report O98.5- (Other viral diseases complicating pregnancy, childbirth and the puerperium) as the primary diagnosis followed by U07.1, has been available since the CDC released guidelines earlier this year. A new paragraph states that when a patient tests positive for COVID-19 during an encounter that is unrelated to the disease the coder should sequence the diagnosis codes as follows: Reason for the encounter, O98.5- and U07.1 followed by any appropriate COVID-19 manifestation codes.
  • When a newborn tests positive for COVID-19 and the provider hasn’t documented a specific method of transmission, assign code U07.1 and the appropriate codes for associated manifestations, a new section in Certain Conditions Originating in the Perinatal Period (P00-P96) states. However, you should code P35.8 (Other congenital viral diseases) followed by U07.1 when the provider documents that the newborn contracted the disease in utero or during birth. The guidance adds that a code from Z38 (Liveborn infants according to place of birth and type of delivery) is the principal diagnosis when coding the birth episode in a newborn record.
  • Remember to look at the revised guidelines for observation codes in Factors influencing health status and contact with health services (Z00-Z99). The new language creates a second exception to the rule that observation codes are primary. “An observation code may be assigned as a secondary diagnosis code when the patient is being observed for a condition that is ruled out and is unrelated to the principal/first-listed diagnosis,” the new guidelines state. The guidelines give the example of a patient who comes in for treatment of injuries sustained during a car accident and who is also observed for a COVID-19 infection that is later ruled out.
  • Don’t bother scrolling to Codes for Special Purposes (U00-U85), for information on vaping-related disorders and COVID-19. The chapter lists the codes and refers you to the appropriate sections in chapter 10: Diseases of the Respiratory System (J00-J99), U07.0 and Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), U07.1, for the guidelines.
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