A quarterly publication of the Central Office on ICD-10-CM/PCS
[Pages:64]A quarterly publication of the Central Office on ICD-10-CM/PCS
Volume 9 Number 1
First Quarter 2022
In This Issue
April 1, 2022 Code Update
4
Changes to the ICD-10-CM
Official Guidelines for Coding
and Reporting
9
New ICD-10-CM Codes
Underimmunization for
COVID-19 Status
4
New ICD-10-PCS Codes COVID-19 Vaccine Administration 6 Introduction of Therapeutic
Substances: Fostamatinib 7 Tixagevimab and Cilgavimab 7 Other Monoclonal Antibody 8
Ask the Editor
Acute Right Posterior Inferior
Cerebral Artery Infarction 25
Admission for Consolidation
Chemotherapy with Bone
Marrow Biopsy
16
Alcohol Abuse in Remission and
Alcoholic Dementia
25
Anxiety with Alcohol Abuse
33
Bacterial Vaginitis in Pregnancy 20
Bulging Disc
26
Cerebral Thrombectomy with
Failed Stent Retriever
Deployment and Aspiration of
Thrombus
43
Common Atrioventricular Valve
Repair with Commissuroplasty
Sutures
41
Dextroconvex and Levoconvex
Scoliosis
30
Diverticulitis with Intra-Abdominal
Abscess
26
Gravid Hysterectomy Due to
Placenta Increta
20
Healing Esophageal Perforation 27
Hemoperitoneum with Splenic
Laceration
22
History of HIV Managed by
Medication
36
Insertion of Amplatzer Occluder
Device into Atrium
37
Insertion, Removal and
Replacement of Endoluminal
Vacuum Application
44
Internal Cardioversion
46
Intrauterine Cook Balloon
Placement for Ectopic
Pregnancy
41
Matrix-Induced Autologous
Chondrocyte Implantation 47
Medical Treatment/Stabilization
of Severe Malnutrition due
to Anorexia Nervosa
13
Newborn Observation due to
Maternal Marijuana Use
18
Newborn Observation for
Possible Subutex?
Withdrawal
17
Newborn Tight Nuchal Cord
22
Nipple Reconstruction and
Breast Reduction
15
Non-Traumatic Spontaneous
Rupture of Eye Globe
33
New code assignments contained in this issue effective with discharges April 1, 2022. Other coding advice or code assignments contained in this issue effective March 18, 2022.
Patient Request for Provider-
Assisted Suicide
29
Percutaneous Ganglion Balloon
Compression
50
Postsurgical Hematoma of
Gallbladder Fossa
24
Present on Admission Indicator
for Palliative Care
18
Procedures Performed on a
Continuous Vessel,
ICD-10-PCS Guideline B4.1c 10
Provisional Total Hip
Arthroplasty
39
Reconstruction of Aorto-Mitral
Curtain Using Bovine
Pericardium
38
Reduction Mammoplasty for
Breast Symmetry
14
Removal of Fat Necrosis from
Retroperitoneum and Space
of Retzius
42
Repair of Common
Atrioventricular Valve Using
Alfieri Stitch
40
Repair of Facial Fractures of
Frontal Sinus and Orbital
Roof
48
Robotic-Assisted Low Anterior
Resection of Colon
49
Ruptured Corpus Luteum Cyst
and Hemoperitoneum
23
Ruptured Ovarian Cyst with
Hemoperitoneum
23
Scintillating Scotoma
30
Septic Arthritis/ Osteomyelitis of
Pubic Symphysis and
Aspiration Biopsy
31
Sigmoid Diverticulitis with
Peritonitis and Perforation 27
Spastic Quadriplegic Cerebral
Palsy with Progressive
Bilateral Hip Subluxation
32
Spontaneous Abortion with
Retained Placenta of Twin B 19
Substance Abuse/ Dependence
with Anxiety, Mood Disorder,
Sleep Disorder, or Sexual
Dysfunction
34
Sunken Flap Syndrome
34
Toxic Shock Syndrome with
Unspecified Sepsis
35
Type 1 Diabetic Hyperglycemic
Hyperosmolar Syndrome 28
Type 2 Diabetic Hyperosmolar
Ketotic State without
Acidosis
28
Underdosing with No Change
in Patient's Condition
36
Umbilical Cord Blood Sampling 48
Clarifications
Intraoperative Serosal Tear
51
Toxic Metabolic Encephalopathy
due to Hepatic
Encephalopathy
52
Correction Notices
Coronary Artery Bypass Graft
Surgery
54
Extraction of Bone Marrow from
Other Sites
54
2
First Quarter 2022
Coding Clinic
Coding Clinic for ICD?10?CM/PCS
Published quarterly by the American Hospital Association Central Office on ICD-10-CM/PCS 155 N. Wacker Drive Chicago, IL 60606.
ISSN 0742-9800
Coding Clinic for ICD-10-CM/PCS Online subscription information can be found at Click Help Center then subscriptions for more information.
Executive Editor Nelly Leon-Chisen, RHIA Director, Central Office on ICD-10-CM/PCS
Editorial Staff, AHA Central Office on ICD-10-CM/PCS
Karen Ayala, RHIT Coding Specialist
Kristina Cool, RHIA, CCS Coding Consultant
Medical Advisors, Centers for Mady Hue, RHIA
Medicare & Medicaid Services Technical Advisor, Technology,
Perry Alexion, M.D.
Coding and Pricing Group
Edith Hambrick, M.D.
Centers for Medicare &
Karen Nakano, M.D.
Medicaid Services, Baltimore
Editorial Advisory Board Donna Ganzer, Chairman President, Ganzer Network Corporation, Great Neck, NY
Chrystel Barron, MHI, RHIA, CPHIMS, CCS, CCS-P, CDIP, CHTS-TR, CICA, CHRI Coding Education Instructor Cleveland Clinic
Edward A. Liechty, M.D. Representative, Amer. Academy of Pediatrics, Indianapolis, IN
Jeffrey F. Linzer, M.D., FAAP Representative, Amer. Academy of Pediatrics, Atlanta, GA
Lee R. Morisy, M.D., FACS Representative, Amer. College of Surgeons, Memphis, TN
Sue Bowman, MJ, RHIA, CCS, FAHIMA Senior Director, Coding Policy and
Compliance, American Health
Bernard Pfeifer, M.D. Representative for American
Medical Assn., Harwich, MA
Information Management Association, Chicago
Donna Pickett, RHIA, MPH Chief, Classifications and
Jonathan Gal, M.D., FASA Mount Sinai Health System
New York, NY
Public Health Data Standards, Centers for Disease Control & Prevention, Hyattsville, MD
Yvonne E. Henderson, CCS, CCS-P, CDIP HIM Coding Quality Supervisor
Evan Pollack, M.D., FACP Representative for Amer. College
of Physicians, Bryn Mawr, PA
Sutter Health Shared Services Melissa G. Roberts, MHA, RHIT
Fairfield, CA
Director Coding Service Center
Centura Health, Centennial, CO
Denene Harper, RHIA Senior Coding Consultant
Diane Komar, RHIT Coding Consultant
Susan Latham, RHIT, CCS Coding Consultant
Anita Rapier, RHIT, CCS Managing Editor Senior Coding Consultant
Cherrsse Ruffin, RHIT Coding Consultant
Kathy White, RHIA Coding Consultant
Subscriptions? Questions? Problems? Call 312-422-3366
Individual answers within AHA Coding Clinic? are available for reproduction by hospitals and health systems for the purpose of responding to payor audit requests. The answer needs to be reproduced in its entirety, and not edited or altered in any way. Payors, consultants, and other for-profit, commercial entities may only use AHA Coding Clinic? content as an internal reference and for audit purposes. AHA Coding Clinic? content may not be utilized for commercial, for-profit purposes and may not be re-sold, repackaged or distributed without the consent of the American Hospital Association Central Office. The Content may not be compiled, shared, or distributed in a way that circumvents the need for an individual or entity to access, purchase, or obtain a license to utilize Coding Clinic content. The use of usernames and passwords should be limited to the purchaser and/or user and not shared with other individuals or entities to circumvent the purchase of an individual license. For more information on obtaining a license to utilize Coding Clinic beyond what is listed above, please contact Tim Carlson tcarlson@.
Gretchen Young-Charles, RHIA Senior Coding Consultant
Coding Clinic is the official publication for ICD-10-CM/PCS coding guidelines and advice as designated by the four cooperating parties. The
Halima Zayyad-Matarieh, RHIA cooperating parties listed below have final approval of the coding advice
Coding Consultant
provided in this publication: American Hospital Association, American
Health Information Management Association, Centers for Medicare &
CDC Medical Officer
Medicaid Services (formerly HCFA), National Center for Health Statistics
David Berglund, M.D. Medical Officer, Centers for Disease Control & Prevention
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please write to the Central Office on ICD-10-CM/PCS, American Hospital
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Coding Clinic
First Quarter 2022
3
APRIL 1, 2022 CODE UPDATE
In the fiscal year 2022 Hospital Inpatient Prospective Payment System final rule published on August 2, 2021, the Centers for Medicare & Medicaid Services (CMS) announced its adoption of an April 1 implementation date for ICD-10-CM and ICD-10-PCS code updates, in addition to the annual October 1 update, beginning with April 1, 2022. Please refer to Coding Clinic Fourth Quarter 2021, page 100, for additional information regarding the addition of April 1, 2022 maintenance of the ICD-10-CM and ICD-10-PCS Coding Systems.
NEW ICD-10-CM CODES
Summary explanations of the ICD-10-CM changes effective April 1, 2022 are provided below. Addenda changes demonstrating the specific revisions to the code titles or instructional notes are not included in the explanations below. Please note that a few addenda changes have been made in the Alphabetical Index and Tabular List unrelated to the new codes described below. The official ICD10-CM addenda has been posted on the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics website at: .
Underimmunization for COVID-19 Status
Code Z28.3, Underimmunization status, has been expanded and three new codes are created to identify:
? Z28.310, Unvaccinated for COVID-19
? Z28.311, Partially vaccinated for COVID-19
? Z28.39, Other underimmunization status
4
First Quarter 2022
Coding Clinic
Additional codes are assigned, if applicable, to provide further information on reasons for underimmunization, such as contraindication (Z28.0-), patient's decisions for reasons of belief or group pressure (Z28.1), patient's decision for other and unspecified reason (Z28.2-), or other reason (Z28.8-).
Codes in sub-subcategory Z28.31, Underimmunization for COVID-19 status, should not be assigned for individuals who are not eligible for the COVID-19 vaccines, as determined by the healthcare provider (e.g., infants too young to receive the COVID-19 vaccines). The ICD-10-CM Official Guidelines for Coding and Reporting have been updated with instructions determining usage of codes Z28.310 and Z28.311 in relation to COVID-19 vaccinations.
Question: A patient presents to the physician's office for an annual check-up and is noted to have received the first dose of a two-dose regimen (e.g., Moderna) COVID-19 vaccine, but has not received the second dose yet. How should the patient's underimmunization status for COVID-19 be reported?
Answer: Assign code Z28.311, Partially vaccinated for COVID-19, since the patient received the first dose of a two-dose regimen.
NEW ICD-10-PCS CODES
A summary of the ICD-10-PCS changes effective April 1, 2022 is provided below. The addenda changes demonstrating the specific revisions to the code titles are not included in the explanations below. The Code Tables, Index and related Addenda files are available on the Centers for Medicare & Medicaid Services (CMS) website at https:// medicare/icd-10/2022-icd-10-pcs.
Nine new procedure codes are created to describe the introduction or infusion of therapeutics, including vaccines, monoclonal antibodies and a drug for COVID-19 treatment.
Coding Clinic
First Quarter 2022
5
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