April 2022 Documentation Updates

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As stated in the FY 2022 IPPS final rule, CMS finalized the implementation of a new Medicare Code Edit for “unspecified” ICD-10-CM diagnosis codes where there are other diagnosis codes available in that diagnosis code subcategory that further specify the anatomic site. The impact of this change should be minor if coders are adhering to the updated ICD-10-CM Official Guidelines for Coding and Reporting for FY 2022 regarding laterality on page 15 which state:

“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. If there is conflicting medical record documentation regarding the affected side, the patient’s attending provider should be queried for clarification. Codes for “unspecified” side should rarely be used, such as when the documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification”

This code edit will be implemented effective with discharges on and after April 1, 2022. A sample of conditions that would be identified with this edit include:

  • Hemiplegia where the affected side and dominance is not specified
  • Pressure ulcer of the buttock of stage 3 or 4 where the side of the buttock is not specified

Additionally, there are three new ICD-10-CM codes, all of which have no impact on MS-DRG assignment but are important for accurate morbidity and mortality statistics:

  • 310 Unvaccinated for COVID-19
  • 311 Partially vaccinated for COVID-19 (which is not clearly defined)
  • 39 Other under-immunization status

ICD-10-PCS codes to capture the introduction of COVID-19 vaccine dose 3/booster subcutaneously or intramuscularly were also added.

Download the complete tip, April 2022 Documentation Updates.