With the implementation of ICD-10 back in October 2015, there came some changes to the Official Guidelines for Coding and Reporting for ICD-10-CM for the 2016 code set. The majority of changes were rewording of guidelines through the addition or deletion of text or moving information from one guideline to another for clarification or to provide additional examples. Since most of the changes don’t involve the addition of new guidelines or the removal of old guidelines they don’t have a major impact on how we code on a day to day basis. Because this is the case, the changes may go unnoticed by many coders. The following are 3 examples that highlight some of the changes:
Injury code 7th character “A”
The definition for the 7th character of “A,” used in trauma codes to indicate an “initial” episode of care was changed as indicated in red:
Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or different physician.
These changes provide additional clarity surrounding what is considered “initial” care of injuries.
Place of occurrence codes
A second paragraph regarding the assignment of place of occurrence external cause of morbidity codes was reworded as follows:
Generally, a place of occurrence code is assigned only once, at the initial encounter for treatment. However, in the rare circumstance that a new injury occurs during hospitalization, an additional place of occurrence may be assigned.
No 7th characters are used for Y92.
The additional wording included in the new guideline provides helpful direction for coders who find themselves faced with unusual or rare coding circumstances.
Another example of additional wording being added to a guideline to provide the coder with helpful direction when making code choices is found in General Coding Guideline 10: Sequela (Late Effects). The following paragraph has been added to provide examples of conditions that would be reported with sequela codes in ICD-10-CM.
Examples of sequela include: scar tissue after a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis.
Being aware of any changes, even minor wording changes, to coding guidelines as a result of the annual updates to ICD-10-CM helps ensure the most accurate code assignment possible is made.
Get a full list of the “Hidden Changes” in the 2016 ICD-10-CM Guidelines at: