April Coding Tip Corner

Although the ICD-10 Coordination and Maintenance Committee is a federal committee, suggestions for coding modifications come from both the public and private sectors. The CDC’s National Center for Health Statistics has the lead on ICD-10-CM diagnosis issues. CMS has the lead on ICD-10-PCS procedure issues. Last year, the CDC announced that effective this year, two significant updates to code sets will happen every year – one in April and one in October.

The April 2023 ICD-10-CM updates include:

• ICD-10-CM: There are 42 additions, seven deletions, and one revision.
• ICD-10-PCS: There are 34 additions, no deletions, and no revisions.
• The updates are effective beginning April 1, 2023.
  
  

Here is a breakdown of the new codes based on the chapter:

• Chapter 19 (12 new codes)
• Chapter 20 (15 new codes)
• Chapter 21 (15 new codes) Some of these codes are dealing with SDOH.

There are also deleted codes in Chapter 21. (Seven of those deleted were codes dealing with SDOH.)

CMS has also revised the code for material hardship to include “due to limited resources, not elsewhere classified.” This code describes when a patient cannot obtain adequate childcare, clothing, utilities, or basic needs due to financial hardship. It appears CMS is taking a hard look at patients’ SDOH!

The Medical and Surgical section:

• Heart and great vessels: 1 new code
• Lower arteries: 1 new code
• Upper bones: 6 new codes
• Lower bones: 6 new codes
  

Deleted codes: Seven (7) from chapter 20; however, they have replaced these with expanded codes in chapter 21.

Administration section:

• Circulatory: 14 new codes 

New Technology section: 

• Covid related: 4 new codes
• Stem Cell Transplant: 2 new codes

The Gold Standard of Documentation
Has your office achieved this? What is the Gold Standard of Documentation? What does it include?

The Gold Standard of Documentation is when another provider can read the notes, clearly identify the service, and perform the service based on what was documented. This type of documentation requires maintaining accurate and complete medical records and documentation of services you provide. This type of service is providing your member quality care in the event you are not available, should an emergency arrive on either side!

Health Awareness Month Events for April
 As noted by Office of the Assistant Secretary for Health (OASH) – HHS.gov:

• National Minority Health Month: The theme for 2023 is Better Health Through Better Understanding.
• Alcohol Awareness Month: This is a great time to recapture the SDOH regarding drinking and smoking for your patients’ records.
• National Public Health Week (April 3-9): Mental Health (Stress Awareness Month) is one of the themes for public health this month as well. Here are five tips for self-care:
  1. Live healthy
  2. Practice good hygiene
  3. See friends
  4. Try to do something you enjoy every day
  5. Find ways to relax