2021 ASC Coding Tips: ICD-10-CM Updates for 2022

By Mandeara Frye, RHIA, CPC, CPMA, CASCC, Director of Coding

Each October, the new ICD-10-CM diagnosis codes go into effect. It’s important to make sure your ASC is prepared for these changes. In this blog post, I'll share some steps to help ensure your transition is as successful as possible. I'll also be taking a look at some important changes for this year that may impact your ASC.

4 Steps for a Successful ICD-10 Transition

1. Update your software. If your practice management system isn’t automatically updated with new codes each year, coordinate with your vendor to come up with a plan of action. Having the new diagnosis codes available on October 1 will help avoid billing delays since new codes may come up as invalid. ICD-10-CM data sets are available to the public from CMS.

2. Review the guideline changes. It’s important to understand the ICD-10-CM guidelines since these drive how the codes are used. Changes to the guidelines will appear in bold text to aid in identifying the differences. Not everyone wants or has the time to read 100-plus pages of guidelines, so we’ll break down some important changes below.

3. Review the code changes. Make sure your coders are prepared for the changes and know what new codes to look for and their appropriate usage. It’s also a good idea to make sure your providers are informed of the new codes as well since they may need to alter their dictation to meet new requirements.

4. Watch the date of service (DOS). Code changes go into effect based on DOS, not coded/billed date, so it’s imperative to make sure the appropriate code is used. No new codes for fiscal year 2022 should be used for any claim prior to date of service Oct. 1, 2021.

Important Guideline Changes

1. Laterality

“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.”

What this means for ASC coding: If laterality is missing from the operative report, it can be taken from other clinical records such as an intraoperative record that is signed by a clinician. It’s important to only take this from clinical records. Coding information should never be based on non-clinical documents such as a consent or scheduling form. Any documentation used must be signed by a clinician.

2. Use of Sign/Symptom/Unspecified Codes

“As stated in the introductory section of these official coding guidelines, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

What this means for ASC coding: Physician documentation remains critical to the coding process. Physicians should document the reason(s) the patient is having a procedure performed in the op report. There are often multiple conditions listed in a history and physical (H&P) report that may or may not be applicable to the current surgical encounter. If a coder requires clarification to avoid using a code that may not meet medical necessity, it would be appropriate for the coder to request the H&P or query the physician.

Important Diagnosis Code Changes

New Codes:

• C56.3 Malignant neoplasm of bilateral ovaries (previously only left, right, unspecified existed)
• C79.63 Secondary malignant neoplasm of bilateral ovaries (previously only left, right, unspecified existed)
• G44.86 Cervicogenic headache
• K22.81 Esophageal polyp
• K22.82 Esophagogastric junction polyp
• K22.89 Other specified disease of esophagus (previously codes as K22.8, 5^th character added)
• K31.A—Gastric intestinal metaplasia (code to appropriate 6^th character)
• L24.A- Irritant contact dermatitis due to friction or contact with body fluids (code to appropriate 5^th character)
• L24.B- Irritant contact dermatitis related to stoma or fistula (code to appropriate 5^th character)
• M54.A- Non-radiographic axial spondyloarthritis (code to appropriate 5^th character)
• M54.50 Low back pain, unspecified
• M54.51 Vertebrogenic low back pain
• M54.59 Other low back pain

The low back pain diagnosis changes are of particular importance for any ASCs that are performing pain management procedures. Surgeons must be aware of how these revisions affect their documentation since they will need to more precisely specify the type of low back pain treated to avoid an unspecified diagnosis.

The importance of physician documentation cannot be overstressed. Make physicians aware of the diagnosis code changes so they can make appropriate changes to their documentation. There are several mentions in the guidelines about coding to the highest level of specificity documented in the medical record. While there are times when an unspecified diagnosis is accurate and appropriate, physicians should always strive to document to the highest level of specificity that is known at the time of the encounter.