ICD-10-CM Coordination and Maintenance Committee: Time to Comment Again

Dr. David Berglund and the folks from the National Center for Health Statistics really do an amazing job of maintaining ICD-10-CM.

Participating in the ICD-10-CM Coordination and Maintenance Committee meetings is a privilege and a responsibility. We have the opportunity to contribute ideas, suggestions, and feedback to the personnel who update the International Classification of Diseases, as clinically modified for the United States. It is one of my most enjoyable experiences of the year.

If you did not participate in real time, I highly recommend you watch the proceedings on demand. At the very least, read the proposals and their background, and provide the Centers for Disease Control and Prevention (CDC) with your input. To access the proposal materials and the recordings, go to https://www.cdc.gov/nchs/icd/icd10cm_maintenance.htm and scroll down to Sept. 14-15, 2021.

After the list of contents on the agenda, the deadlines for comment submission are laid out. There are some codes that are being considered for implementation on April 1, 2022, and public comments on these proposed codes are due on Oct. 15. The remainder of the comments are due Nov. 15. Comments on diagnosis proposals should be sent to nchsicd10CM@cdc.gov.

I’m going to give you a few of my opinions here, and feel free to borrow any ideas you agree with.

• I think the dementia expansion is quite comprehensive. I would change the word “or” for “and” in the titles which include without behavioral disturbance, psychotic disturbance, mood disturbance, and I know about the rule where “and” means either, but it just doesn’t make sense to me. There will need to be guidance to utilize as many codes as are applicable.

• They are proposing an expansion to Z08, Encounter for follow-up examination after completed treatment for malignancy neoplasm to “after surgery,” “after radiotherapy,” and “after chemotherapy.” I would like to see instructions on how long after treatment these codes are able to be utilized (forever?), and whether you use “after other treatment” if the patient has had multiple modalities.

• There was a common theme in proposals wherein some subspecialty organization wants greatly detailed specificity for research and statistics, and they forgo an unspecified variety of the condition. Makes sense for the subspecialist, but I was an emergency physician, and I see a need for “unspecified.” Extraocular muscle entrapment and Immunoglobulin A nephropathy come to mind.
• The Agency for Healthcare Research and Quality (AHRQ) requested codes for immune-mediated and non-immune-mediated heparin-induced thrombocytopenia, and for vaccine-induced thrombotic thrombocytopenia. The latter has been seen with the Janssen COVID-19 vaccine, so there was a suggestion to move up the time frame for this one to April 1.

• A dedicated code for hepatic encephalopathy has been proposed, but it does not include West Have Criteria Grade 4, which is hepatic coma. My suggestions were that there needs to be an Excludes1 for hepatic coma, and that it is at least a comorbid condition (CC).

• There is a recommendation to add codes for traumatic brain injuries detailing loss of consciousness as unknown. There will be an LOC status unknown and an unspecified duration of LOC. This is welcome.

• Long-term drug therapy is proposed to get quite an expansion. I feel sorry for the coders who will have to sort out which drugs will be coded and which one to use, but I think it is important information.

• They are proposing a malignant pericardial effusion code, I31.31. I wonder if there shouldn’t be two codes: a malignant pericardial effusion, and a pericardial effusion due to disease classified elsewhere?

• I had some issues with the proposed expansion of non-traumatic peritoneal hemorrhage. Although we were told that this mirrors the World Health Organization’s (WHO’s) ICD-10 coding set, it does not make clinical sense to code retroperitoneal hemorrhage under an R signs/symptoms code, but retroperitoneal hematoma under R68.3. WHO does not have dedicated codes for retroperitoneal disease other than K66.2, retroperitoneal fibrosis. There also is a proposed code for R58.83, Ruptured vessel (blood). What vessel, and where? This needs more clarification.

• Parkinson’s disease is getting expanded with dyskinesia and OFF episodes. As mentioned above, an unspecified Parkinson’s disease code needs to be retained. They offered G20.C, Parkinsonism, unspecified, but this is not the same.

• They are proposing adding several other categories of perpetrators of assault, maltreatment, and neglect. I believe they need to add the word “alleged,” not only to the newly proposed codes, but to all prior ones in this section. In medicine, we do not make legal determinations.

• Postural orthostatic tachycardia syndrome is being offered a code, G90.A. I think the acronym POTS needs to be included somewhere, either in the title as a parenthetical or as an inclusion term. We are seeing it with COVID-19, so fast-tracking it to April 1 may be in order.

• Post-viral and related fatigue syndromes: this is another COVID-19-related condition, so I suggested moving up the deadline for this one, and there should be an instruction to code U09.9 when applicable. I am not clear on what the coder does with verbiage of “post-viral chronic fatigue syndrome.” Is that G93.31 or G93.32?

• They are proposing a fast-tracked Z28.31, Under-immunization for COVID-19.

• I think we are hard-pressed to call a patient “under-immunized” if there is no mandate for vaccination.
• The question we are really asking is, “are they immunized?” My recommendation is that we need a personal history of COVID-19 vaccination code set (e.g., Z92.261 Personal history of COVID-19 vaccination, complete series; Z92.262 Personal history of COVID-19 vaccination, incomplete series; and Z92.268 Personal history of COVID-19 vaccination, unspecified).

• My next comment regards transgender individuals. In the index, they are adding F64.9, Transgender. Do we need a code for transgender status? Is being transgender being labeled a disorder, or is it just important to know what someone’s biological birth sex was so we don’t error out on concordant sex-related conditions (e.g., prostate cancer in a trans woman)?

• The OB diagnoses have perplexed me, as noted in my TalkBack.
  • I think the first thing the CDC needs to do is align spontaneous onset of labor according to the American College of Obstetrics and Gynecology’s (ACOG’s) schema. Early-term pregnancy goes from 37 0/7 week to 38 6/7 week; full-term spans 39 0/7 week to 40 6/7 week; late-term is 41 0/7 week to 41 6/7 week; and post-term encompasses 42 0/7 week and beyond. The proposal cherry-picked the early term because ACOG recognizes poorer outcomes as compared to full term, and they suggested a code of O75.83, Onset (spontaneous) of labor after 37 completed weeks of gestation – but before 39 completed weeks of gestation, with vaginal delivery. If you want robust data, get all the data needed, so let’s codify every spontaneous onset of delivery. I’m not sure where the full-term spontaneous labor code would be housed, as it isn’t abnormal (O75 is other complications of labor and delivery, NEC).
  • If we had a code that captured onset of spontaneous labor, we could eliminate O80, because the procedure utilized to deliver that product of conception would be embedded in the PCS code. We wouldn’t need the newly proposed O81, because the fact that there was a vacuum or forceps extraction delivery would again be captured in the PCS code. We also wouldn’t use POA-N conditions as principal diagnoses; they would be relegated to secondary diagnoses, and doesn’t that seem more normal?

My last comment is that Dr. David Berglund and the folks from the National Center for Health Statistics really do an amazing job of maintaining ICD-10-CM. Orchestrating the meeting virtually and collaborating with the presenters must be a tremendous endeavor. Kudos to them. Be part of the action – read the proposals and submit your comments!

Programming Note: Listen to Dr. Erica Remer every Tuesday when she co-hosts Talk Ten Tuesdays with Chuck Buck at 10 Eastern.