Health Information Management

Get to know the 2012 ICD-10-CM guideline changes

JustCoding News: Inpatient, April 25, 2012

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Inpatient!

The additions and revisions to the ICD-10-CM Official Guidelines for Coding and Reporting in 2012 include some new information that coders should be aware of in preparation for ICD-10 implementation.

"They've done a good job of taking the previous guidelines and reworking them for 2012," says Sandy Nicholson, MA, RHIA, vice president of health information services for DCBA, Inc., an Atlanta-based consulting company. Now coders just need to familiarize themselves with the changes.

Probably the biggest change in the guidelines is the requirement for a causative link between a complication and a procedure, Nicholson says. Coders may only assign a complication of care when the provider documents a cause-and-effect relationship. "Coding Clinics have given us guidance on that for a long time … but the ICD-10 guidelines really come out and talk about it."

This requirement will probably lead to additional queries, she notes. As Coding Clinic indicated for ICD-9-CM, if the physician doesn't document a cause-and-effect relationship (e.g., for postop bleeding), coders need to query the physician regarding whether a complication is directly related to the procedure. That said, not all coders may do so in ICD-9-CM. That changes with ICD-10-CM. "The ICD-10 guidelines make it very clear that we have an obligation to query. We can't just use the ICD-9 version of the 900 codes. We can't just make that assumption anymore just because the physician says it is postop," Nicholson says.

Similarly, if a patient returns from the procedure room and spikes a fever or has high blood pressure while in recovery, coders can't assume these conditions are complications of the procedure, says Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer of Safian Communications Services in Orlando, FL.

"You would have to have the physician document the underlying cause of the fever. If it is expected that their blood pressure is going to spike or they'll have a fever, then that's not a complication," she says.


Another significant change for 2012 is the addition of an entirely new set of guidelines for glaucoma. They're very specific, Nicholson points out, and current levels of documentation may not be adequate. "We need to be aware of that and start discussing whether we want to query," she says. "I personally have not ever seen a ¬patient admitted for glaucoma; it's just not heard of much. But potentially it's going to be important down the road that we have that stage and type."

Note the following guidelines:

  • When a patient has bilateral glaucoma and the physician documents both eyes as being the same type and stage, and a code for bilateral glaucoma exists, ¬report only the code for the type of glaucoma, bilateral, with the seventh character for the stage. If there is no code for the bilateral glaucoma under these circumstances (i.e., with subcategories H40.10, H40.11, and H40.20), report only one code for the type of glaucoma with the appropriate seventh character for the stage.
  • When a patient has bilateral glaucoma but each eye has a different type or stage, and the classification distinguishes laterality, assign the appropriate code for each eye rather than the code for bilateral glaucoma. For patients with a different type of bilateral glaucoma in each eye but without classification for laterality, coders should assign one code for each type of glaucoma with the appropriate seventh character for the stage.
  • Finally, when a patient has bilateral glaucoma of the same type in each eye but in different stages, and the classification does not distinguish laterality, ¬coders should assign a code for the type of glaucoma for each eye with the seventh character for the stage documented for each eye.

The guidelines also address the use of the seventh character "4" (indeterminate stage):

The seventh character "4" is used for glaucomas whose stage cannot be clinically determined. This seventh character should not be confused with the seventh character "0", unspecified, which should be assigned when there is no documentation regarding the stage of the glaucoma.

The coding guidelines also note that if a patient's glaucoma progresses during admission, coders should report the highest stage documented.


There are a few important changes to the guidelines for neoplasm coding as well.

ICD-10-CM guidelines instruct coders to classify a primary malignant neoplasm that overlaps two or more contiguous sites to the subcategory/code .8 (i.e., "overlapping lesion"), unless the combination is specifically indexed elsewhere. Look at code C85.28 (mediastinal [thymic] large B-cell lymphoma, lymph nodes of multiple sites) as an example, Safian says.

In addition, the guidelines state that coders should assign a code for each site when multiple neoplasms of the same site aren't contiguous, such as tumors in different quadrants of the same breast.

The new guidelines also address malignant neoplasms of ectopic tissue, stating, "Malignant neoplasms of ectopic tissue are to be coded to the site mentioned, e.g., ectopic pancreatic malignant neoplasms are coded to pancreas, unspecified (C25.9)."

Ectopic tissue is tissue located somewhere it shouldn't be, just as an ectopic pregnancy is one where the embryo implants in a place outside of the uterus, Nicholson explains.

Anemia associated with chemotherapy

When a patient is admitted or sees a provider for management of anemia associated with a malignancy, and receives treatment only for anemia, report the code for the malignancy as the principal or first-listed diagnosis followed by the appropriate code for the anemia, according to the 2012 guidelines. Further, when a patient has anemia associated with an adverse effect of chemotherapy or immunotherapy and receives treatment only for the anemia, coders should sequence the anemia code first followed by the appropriate codes for the neoplasm and the adverse effect.

"There are some changes made to how we sequence anemia with neoplasm," Nicholson explains. "With ICD-10, we will be assigning the malignancy as the principal diagnosis. If it's just an anemia associated with a malignancy, the malignancy is sequenced as principal; the anemia is secondary."

However, situations where anemia is associated with chemotherapy haven't really changed. "So that's a good thing, and that is familiar to us," Nicholson says. "We do sequence the anemia code first, but it's now considered an adverse effect and we would code the adverse effect secondary."

Other changes

The official guidelines included several other changes for 2012, including:

  • Pain disorders related to psychological factors. A new note instructs coders not to report code G89 (pain not elsewhere classified) when documentation supports a psychological component for the pain. In that case, coders should go back to code S45.41, Nicholson explains, noting that such a distinction hadn't previously existed.
  • Syndromes. If no code exists for a particular syndrome, ICD-10-CM guidelines now state that coders should report the manifestations (e.g., those conditions identified as a result of the patient having that syndrome) instead, Safian says. "But the connection has to be documented by the physician to qualify," she points out.
  • Conditions affecting organ transplant. Per the guidelines, coders should assign a code from category T86.xx (complications of transplanted organ) as well as an additional code identifying the specific complication. "This specifically now says that the complications of the transplanted organ code should be reported first," Safian explains. "Previously there was no guideline regarding order, so this addition makes sense."
  • Late effects (i.e., sequela). Coders won't be using the term "late effects" any longer, but instead will look for the word "sequela." "It makes perfect sense and really correlates with the use of sequela in the seventh digit characters in the musculoskeletal system," Nicholson says.
  • Coders need to pay attention to these new guidelines, Nicholson says. "I would highly recommend that all coders have a copy of the ICD-10 guidelines and review them periodically. Even though we aren't held to these guidelines right now, we need to be ready to apply them as soon as we start assigning ICD-10 codes, which we will all be doing for practice so when the drop-dead date arrives, we'll be ready."

Coders should familiarize themselves with new terminology, such as sequela, and highlight changes that will be of particular importance for their organization and their own coding, she advises. "Like the time period for the acute myocardial infarction--that's changing to four weeks and we're used to eight weeks. We're going to have to be aware of that," Nicholson says. "So keep looking for those changes."

Editor’s note: This article was originally published in the May issue of Medical Records Briefing. Email your questions to Senior Managing Editor Andrea Kraynak, CPC, at

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Inpatient!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular