Clearing Up Confusion Over ICD-10-CM Guidelines

The Health Insurance Portability and Accountability Act (HIPAA) requires covered entities to adhere to the most current International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code set as well as ICD-10-CM guidelines.

It is important that the Academy be made aware of payers that do not follow ICD-10-CM guidelines as this is a direct HIPAA violation. It is equally important for members to know the guidelines when reporting services.

A few guidelines are still causing confusion, and they are addressed here.

Outpatient reporting

The outpatient reporting rules state: “Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

This means you can never report a condition that does not exist or you are clinically uncertain if it exists. If the patient presents with signs or symptoms, you would report those. If the patient is asymptomatic, you must report a code from the “observation for suspected conditions” categories Z03, Z04, Z05. Report a code from these categories when a patient presents because the parent believes the child has a condition, but after further review, the condition does not exist.

Injury reporting

Under injury reporting, 7th character “S,” sequela “is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using 7th character “S,” it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code. The 7th character “S” identifies the injury responsible for the sequela. The specific type of sequela (e.g., scar) is sequenced first, followed by the injury code.”

The aftercare Z codes “should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care. For example, for aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent encounter).”

Q: A 1-year-old patient is seen in the office after a fall off the couch. The mom was concerned about possible injuries. None were noted, and the physician documents “observation after fall, no injuries.” The physician instructs the mom on what to look for in case something develops, but at this time the patient is fine. What ICD-10-CM code should be reported?

A: You would report a code to show that the patient presented after an accident (fall), but no injuries or issues were discovered. Z04.3 Encounter for examination and observation following other accident

Q: A patient is seen for recent onset of headaches. The patient suffered a concussion three months prior but had since been cleared and was doing OK. There is no other known cause of the headaches, so the physician notes that they are due to the previous concussion. What ICD-10-CM codes should be reported?

A: You would first list the sequela (headache) followed by the original injury code with the 7th character for sequela, “S”

R51 Headache

S06.0X0S Concussion without loss of consciousness, sequela

Q: A patient returns after having sutures placed in the right forearm. The patient’s laceration has healed, and the sutures are removed. What ICD-10-CM code is reported?

A: This encounter is related to aftercare for an injury. You will report the original injury code with 7th character “D” to denote that this is subsequent care for the injury. Do not report any “aftercare codes.”

S51.811D Laceration without foreign body of right forearm, subsequent encounter

Q: A patient returns to his general surgeon to have dressings changed on a recent procedure. What ICD-10-CM code is reported?

A: This encounter is unrelated to an injury, so the aftercare codes are applicable.

Z48.01 Encounter for change or removal of surgical wound dressing


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