The annual changes to the ICD-10-CM[i] coding system come in two forms. The Coding and Reporting Guidelines describe how the codes are to be used, and then there is the list of available codes themselves. 159 new codes became effective on October 1, 2021, and many codes have been revised or deleted. Not surprisingly there are a few revisions to the reporting of COVID-19 infections and related conditions.

Reporting COVID-19

In 2020 the new code U07.1 was introduced to code a confirmed diagnosis of COVID-19 as documented by the provider, or with documentation of a positive COVID-19 test result, whether the patient is symptomatic or asymptomatic. Now we have the code U09.9 Post-COVID-19 condition, unspecified that has been added for reporting late effects of COVID-19. This new code should be used in place of B94.8 Sequela of other specified infectious and parasitic diseases. U09.9 may be used in conjunction with U07.1 when a patient who has had a previous infection has been reinfected with another case of COVID-19, but it should not be used for manifestations of an active (current) COVID-19 infection.

Changes to the Coding and Reporting Guidelines

Describing laterality is always important in radiology reporting. The guidelines now state that, “when laterality is not documented by the patient’s provider, code assignment for the affected side may be based on medical record documentation from other clinicians.” Such clinicians might include a dietitian, nurse, social worker, or emergency medical technician (EMT).

Specific diagnosis codes should be used when they are supported by the available medical record documentation and the physician’s knowledge of the patient’s health condition.   When a definitive diagnosis has not been established by the physician, coding may be done using symptoms and signs. The revised guidelines have highlighted this point by stating, “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

The ICD system includes a series of Z-codes that do not describe a patient’s diagnosis, but rather they provide additional information relevant to the encounter. Radiologists might use such codes in emergency department cases to enhance the information in the medical record. A new section titled Social Determinants of Health (SDOH) was added in the new release, indicating that these codes should be assigned when relevant information is documented. Documentation in this case can include patient self-reported information that is signed-off by and incorporated into the medical record by a provider or a clinician such as a social worker, community health worker, case manager, or nurse. It can also include information provided directly by those clinicians that is included in the medical record. SDOH codes are located primarily in these Z-code categories:

• Z55  Problems related to education and literacy
• Z56  Problems related to employment and unemployment
• Z57  Occupational exposure to risk factors
• Z58  Problems related to physical environment
• Z59  Problems related to housing and economic circumstances
• Z60  Problems related to social environment
• Z62  Problems related to upbringing
• Z63  Other problems related to primary support group, including family circumstances
• Z64  Problems related to certain psychosocial circumstances
• Z65  Problems related to other psychosocial circumstances

Coding Revisions

Of the 159 new codes, relatively few would be important to radiology. In most cases the new codes provide more specificity than the previous code assignment. Here is a selection of examples:

Action Steps

This is just a brief overview of the many changes to ICD-10 coding that are effective now, as of October 1, 2021. Radiology practices should carefully review in detail those codes that will affect their practice and make appropriate adjustments to their templates and EHR systems. Particular attention should be given to codes that have been deleted, as their use could cause claims to be rejected by payers. The reporting guidelines should also be thoroughly reviewed to determine where the practice’s documentation might need to be modified.

The annual revision of the CPT^®[i] (Current Procedural Terminology) code set that takes effect at the beginning of each year is generally of greater impact than the ICD coding changes. Watch for our full coverage of the important coding changes for radiology. Subscribe to this blog to keep abreast of coding changes and other news that affects your practice.

[i] ICD stands for International Classification of Diseases, the system owned and copyrighted by the World Health Organization that is used to report diagnoses when submitting claims for reimbursement of physician services, among many other purposes. ICD-10 is the 10th edition of this coding system.  CM stands for the Clinical Modification of the classification system.

^[ii] CPT® is a registered trademark of the American Medical Association.

Erin Stephens, CPC, CIRCC  is the Sr. Client Manager, Education at Healthcare Administrative Partners. 

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