The days are getting longer, the air a little crisper, the eastern states are showing signs of fall colors – it must be time to update the ICD-10-CM diagnosis codes. A short blog cannot cover every change, but we want to highlight those frequently used within Practice EHR.

• a patient's history of HIV that managed by medication(s) (see Z79.899)
• the underlying cause of anemia (see D55.x)
• insulin use for patients with 2ndry diabetes mellitus (see Z79.x)
• secondary codes for patients with depression (see F78.x)
• Neurotoxicity syndrome (see G92.x)
• Cervicogenic headaches (see G92.8)
• Non-ischemic myocardial injury, non-traumatic (see I5A)
• Esophagogastric polyps (K22.x)
• Irritant contact dermatitis (L24.x)
• Low back pain – M54.5 will no longer be a valid code (see M54 for the new codes and additional                          subcategories)
• Feeding difficulties (see R63.x)
• Cough – R05 will no longer be a valid code (see R05 for the six new codes)
• Traumatic brain compression and herniation (see S06.x)
• Complications of immune effector cellular therapy (see T80.x)
• Distinction between a history of suicidal behavior and non-suicidal self-harm (see Z91.5)
• Post COVID-19 conditions (see U09.9)

As stated in the introductory section of the ICD-10-CM Official Guidelines for Coding and Reporting, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. We cannot overemphasize enough the importance of consistent, complete documentation in the medical record. Without such documentation, your practice can’t achieve accurate coding. The entire clinical record should be reviewed to determine the specific reason for the encounter and the conditions treated.

These changes will not be visible within Practice EHR until October 1, 2021. Still, we recommend that each practice review templates, order sets, superbills, and encounter forms to anticipate necessary changes and prepare for the 10/1 start date. We are happy to help you with any questions or requests for changes. Just reach out to the client services team.