2020 CC CM and Pcs q4

A quarterly publication of the
Central Office on ICD-10-CM/PCS

Volume 7 Fourth Quarter
Number 4 2020
In This Issue Headache with Orthostatic
Changes to the ICD-10-CM Component 38
Official Guidelines for Hepatic Fibrosis 30
Coding and Reporting 80 Hereditary Corneal Dystrophy 24
Changes to the ICD-10-PCS Hypereosinophilic Syndromes and
Official Guidelines for Other Eosinophil Diseases 8
Coding and Reporting 93 Immunodeficiency Status 10
Frequently Asked Questions Intracranial Hypotension 23
Regarding ICD-10-PCS Irregular Eye Movement 25
Coding for COVID-19 95 Joint Related Disorders of Other
Specified Site 31
New/Revised ICD-10-CM Codes Juvenile Osteochondrosis of Tibia
Acquired Autoimmune and Fibula 33
Hemolytic Anemias 7 Maternal Care for Other Type Scars
Adverse Incidents due to from Previous Cesarean Delivery 36
Therapeutic and Rehabilitative Neonatal Cerebral Infarction 37
Ophthalmic Devices 41 Ogilvie Syndrome 29
Aromatic L-Amino Acid Osteoporosis Related Pathological
Decarboxylase Deficiency 15 Fractures 32
Arthritis and Arthropathy of Other Specified Diseases and
Temporomandibular Joint 32 Conditions Complicating
Babesiosis 5 Pregnancy, Childbirth and the
Cerebrospinal Fluid Leak 21 Puerperium 36
Complications of Corneal Perineural Cyst 22
Transplant 40 Powassan Virus Disease 4
Congenital Myopathies 19 Progressive Fibrotic Interstitial
Cyclin-Dependent Kinase-Like 5 Lung Diseases 27
Deficiency Disorder 18 Pulmonary Eosinophilic Diseases 25
Cytokine Release Syndrome 12 Sickle-Cell Disorders 6
C3 Glomerulopathy 34 Stage 3 Chronic Kidney Disease 35
Dravet Syndrome 19 Superficial Injury of Thorax 39
Electric Scooter and Other Micro- Synthetic Narcotics 40
Mobility Devices 41 Withdrawal Syndrome in Substance
Elevated Liver Enzymes 39 Use and Abuse 16
Esophagitis 28
Friedreich Ataxia 17 Z Code Update
Glucose Transporter Deficiencies 16 Observation for Suspected
Granulomatous Mastitis 35 Conditions Ruled Out 42
New codes contained in this issue effective with discharges October 1, 2020. Other
coding advice or code assignments contained in this issue effective October 2, 2020.
New/Revised ICD-10-PCS Codes Introduction of New Therapeutic
Atrium Bypass Qualifier 44 Substances 72
Bacterial Autofluorescence Atezolizumab Antineoplastic 76
Detection 68 Brexanolone 73
Bone Marrow Body Part 53 Cefiderocol Anti-infective 75
Bypass Pancreatic Duct to Stomach 53 Ceftolozane/Tazobactam Anti-
Cesium 131 Brachytherapy 69 Infective 75
Extraction of Ectopic Products of Durvalumab Antineoplastic 74
Conception 59 Eculizumab 76
Fluorescence Imaging of Eladocagene Exuparvovec 73
Hepatobiliary System 66 Esketamine Hydrochloride 76
Insertion of Other Device into Lefamulin Anti-infective 74
Subcutaneous Tissue and Fascia 54 Mineral-based Topical
Insertion of Radioactive Element 43 Hemostatic Agent 74
Insertion of Subcutaneous Pump Nerinitide 74
System for Ascites Drainage 55 Omadacycline Anti-infective 75
Intercompartmental Pressure
Measurement 63 Measurement of Infection 78
Intramedullary Sustained Nucleic Acid-base Microbial
Compression Joint Fusion 56 Detection 79
Intraoperative Radiation Therapy 70 Positive Blood Culture
Intravascular Lithotripsy 50 Fluorescence Hybridization 78
Intravascular Ultrasound Assisted
Thrombolysis 49 Transfusion of Chimeric Antigen
Male Reproductive Organ Transplant 58 Receptor (CAR) T Cells 77
Measurement of Intracranial Brexucabtagene Autoleucel
Arterial Flow 62 Immunotherapy 77
Near Infrared Spectroscopy for Lisocabtagene Maraleucel
Tissue Viability Assessment 65 Immunotherapy 78
New Fragmentation Tables 45
Other Imaging Type 66 Ask the Editor
Percutaneous Endoscopic Acute Respiratory Failure
Measurement of Portal Progressing to Acute
Venous Pressure 62 Respiratory Distress
Removal of External Fixation Device 56 Syndrome 96
Transapical Mitral Valve Repair with COVID-19 with Presumptive Test
Device 52 Results 99
Transfusion Stem Cell Progenitor Critical Limb Ischemia 98
Cells 60 HIV Disease 97
Transvaginal Drainage of Pelvis 56 Palliative Care for Non-Terminal
Ventilatory Assistance by High Patients 98
Flow or High Velocity Nasal Robotic-Assisted Prostatectomy
Cannula Devices 64 with Extension of Incision for
Specimen Removal 99
Section X - New Technology Robotic-Assisted Sigmoid
Cerebral Embolic Filtration Colectomy with Extension of
Extracorporeal Flow Incision for Specimen
Reversal Circuit 70 Removal 100
Implantation of Vertebral
Mechanically Expandable
Device 72
2 Fourth Quarter 2020 Coding Clinic

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Coding Clinic Fourth Quarter 2020 3

ICD-10-CM NEW/REVISED CODES
Summary explanations of the Fiscal Year 2021 (FY 2021) ICD-10-
CM changes effective October 1, 2020 are provided below. Addenda
changes demonstrating the specific revisions to the code titles or
instructional notes are not included in the explanations below. The
official ICD-10-CM addenda has been posted on the Centers for
Disease Control and Prevention (CDC) National Center for Health
Statistics posted at https://www.cdc.gov/nchs/icd/icd10cm.htm.
There are 490 new ICD-10-CM codes effective October 1, 2020. In

addition, there are 47 revised codes and 58 codes have been deleted.
Powassan (POW) Virus Disease
Subcategory A84.8, Other tick-borne viral encephalitis, was expanded

and code A84.81, Powassan virus disease, has been created to
specifically identify this disease.
Powassan (POW) virus disease is a tick-borne zoonosis caused

by the bite of an infected tick, mostly Ixodes scapularis. Although
a person who is infected may not develop symptoms immediately
due to a long incubation period of one week to one month, POW
virus is a serious disease that usually results in encephalitis and/
or meningitis and may lead to death. Symptoms can include fever,
headache, vomiting, weakness, confusion, loss of coordination,
speech difficulties, and seizures. POW virus infections may also be
transmitted through the transfusion of blood and blood components
collected from an infected donor. Although POW virus disease is
considered rare, the number of reported neuroinvasive cases have
increased considerably in recent years. As POW virus disease is
transmitted by the commonly found tick species, Ixodes scapularis, it
is expected that cases of POW virus disease will continue to rise and
potentially pose a threat to the safety of blood supply.

The creation of this code will improve coding accuracy, increase
provider and, consequently, population awareness of this serious
neuroinvasive disorder. This will allow the ability to monitor spread
of the disease locally and nationally, and therefore help in the
development of appropriate prevention strategies to stop spread of
the disease and assure safety of the blood supply. Code A84.89 will
identify other tick-borne viral encephalitis.
Babesiosis
Code B60.0, Babesiosis, was expanded and new codes created

for specific species of Babesia. Human babesiosis is a tick-borne
zoonosis caused by intra-erythrocytic protozoa of the genus Babesia.
The majority of U.S. babesiosis cases are caused by B. microti
(B60.01), which is prevalent in the Northeast and upper Midwest.
However, other Babesia species such as B. duncani (B60.02), B.
divergens (B60.03), and other species (B60.09) have been implicated
in transmission in multiple U.S. states. Babesiosis, unspecified is
classified to code B60.00.
As the majority of Babesia infections are presumed to be

asymptomatic and may never be diagnosed, especially in younger
persons, babesiosis may persist undetected. Transfusion of blood and
blood components collected from asymptomatic donors may result in
transfusion-transmitted babesiosis (TTB), leading to a potentially fatal
clinical illness in blood transfusion recipients.
Over the past decade, there have been a growing number of reported
cases in the United States, including TTB cases. Babesiosis infections
have also been spreading to non-endemic states. In response, efforts
are being made to mitigate the risk of human babesiosis infections,
including the development of donor screening tests and testing
strategies.
The addition of species-specific Babesia coding will enable the Food

and Drug Administration (FDA) to monitor spread of different Babesia
species in the U.S. by states and counties of residence, as well as
from disease endemic areas to non-endemic areas, thus allowing the
FDA to recommend appropriate donor testing strategies to prevent
transfusion transmission of different Babesia species.

This request for new specific codes for multiple species of Babesia
was received from the Office of Biostatistics and Epidemiology, Center
for Biologics Evaluation and Research (CBER), of the FDA.
Sickle-Cell Disorders
Codes were created in category D57, Sickle-cel disorders, to identify

sickle-cell disease (Hb-SS disease, sickle-cell/Hb-C disease, sickle-
cell thalassemia, and other sickle-cell disorders) with cerebral
vascular involvement (D57.03, D57.213, D57.413, D57.813) and with
crisis with other specified complication (D57.09, D57.218, D57.418,
D57.818).
Cerebral infarct and cerebral ischemia are major complications in

patients with sickle-cell disease. Children are at risk for symptomatic
stroke that can cause learning problems and lifelong disabilities.
Treatment for stroke prevention includes regular blood transfusions
and in selected cases, hematopoietic stem cell transplantation. Other
specified complications of sickle-cell disease may include acute
gallbladder involvement, priapism and fever.
In addition, codes were created in subcategory D57.4, Sickle-cell

thalassemia, for sickle-cell thalassemia beta zero (HbS-β0) and
sickle-cell thalassemia beta plus (HbS-β+), and common crises
associated with these conditions. Specifically, unique codes were
created for HbS-β0 and HbS-β+ respectively as follows:
• Without crisis (D57.42, D57.44),

• With acute chest syndrome (D57.431, D57.451),
• With splenic sequestration (D57.432, D57.452),
• With cerebral vascular involvement (D57.433, D57.453),
• With crisis with other specified complication (D57.438,
D57.458), and
• With crisis, unspecified (D57.439, D57.459).
In addition to the abnormal sickle shape of the red blood cells

associated with sickle-cell disease, individuals with sickle-cell beta
thalassemia have an abnormal beta globin chain (βS) with a defective
beta globin gene that affects the production of hemoglobin. The beta
globin gene is either decreased in synthesis (sickle-cell thalassemia
beta plus (HbS-β+) or absent of synthesis (sickle-cell thalassemia
beta zero (HbS-β0). The amount of hemoglobin is either reduced or

no normal hemoglobin is produced by the red blood cells. The amount
of normal hemoglobin in the body affects the severity of symptoms.
Symptoms of HbS-β0 are similar to sickle-cell disease. Patients may
experience acute and chronic complications such as anemia, stroke,
vaso-occlusive pain, acute chest syndrome and splenic sequestration.
The manifestations of HbS-β+ are significantly less severe and there
is little or no anemia.
Acquired Autoimmune Hemolytic Anemias
Code D59.1, Other autoimmune hemolytic anemias, was expanded

and codes were created for unspecified and other autoimmune
hemolytic anemia and three specific types of temperature-sensitive
acquired autoimmune hemolytic anemias: warm, cold and mixed type:
• D59.10 Autoimmune hemolytic anemia, unspecified

• D59.11 Warm autoimmune hemolytic anemia
• D59.12 Cold autoimmune hemolytic anemia
• D59.13 Mixed type autoimmune hemolytic anemia
• D59.19 Other autoimmune hemolytic anemia
Acquired autoimmune hemolytic anemia (AIHA) occurs when

autoantibodies cause destruction of red blood cells (RBCs). The lack
of RBCs to carry oxygen throughout the body deprives the organs
of oxygen and causes anemia. AIHA can occur at any age. It can be
primary (idiopathic), secondary to infection or associated with B-cell
lymphomas, Hodgkin’s disease, hepatitis, or associated with primary
immunodeficiencies or autoimmune disease. Temperature sensitive
AIHA describes the destruction of RBCs that occurs above and below
the normal temperatures of the body.
Warm hemolysis, the most common type of temperature-sensitive

AIHA occurs when immunoglobulin G (IgG) autoantibodies bind to
RBCs at body temperatures equal to or greater than the normal
body temperature. Less often, IgM and IgA autoantibodies cause
the hemolysis. Symptoms of exertional shortness of breath, fatigue,
dizziness and heart palpitations may appear gradually or suddenly
over a few days. The onset depends on the rate of the destruction
of RBCs and the underlying disorder. Warm AIHA may be idiopathic
or associated with lymphoma or chronic lymphocytic leukemia
of autoimmune diseases like systemic lupus erythematosus.
Transfusions are required for patients who develop life-threatening
anemia. Corticosteroids are the first-line of treatment to achieve stable

RBC values and maintain remission. Immunosuppressive drugs may
also be necessary for long-term management. Splenectomy may be
required in severe cases.
In cold hemolysis or cold agglutinin disease, immunoglobulin M (IgM)

autoantibodies bind to RBCs at 32-50°F. The individual’s hands and
feet may become cold, painful and turn a bluish color in addition to
weakness and shortness of breath due to lack of oxygen. Cold AIHA
may be primary, or of unknown cause, but almost all cold AIHAs are
secondary to an underlying condition such as autoimmune disease,
lymphoma or infections like mononucleosis and mycoplasma
pneumoniae infection. Cold avoidance and treatment of the underlying
cause of the condition is the focus of treatment. Rituximab, a
monoclonal antibody, is effective in reducing specific types of immune
cells by targeting the white blood cells that make the autoantibodies
that destroy the healthy RBCs. Plasmapheresis to remove antibodies
has a short term effect during acute hemolytic crisis. Transfusions are
performed sparingly and require warming of the blood through an on-
line warmer.
A person with mixed type autoimmune hemolytic anemia has severe

intermittent exacerbations due to having both the warm type and cold
type autoantibodies. RBCs are destroyed at either normal or lower
temperatures. Corticosteroid therapy is the main treatment.
Hypereosinophilic Syndromes and Other

Eosinophil Diseases
Code D72.1, Eosinophilia, was expanded and the following codes
were created for hypereosinophilic syndromes and other eosinophil
diseases.
D72.10 Eosinophilia, unspecified

D72.110 Idiopathic hypereosinophilic syndrome [IHES]
D72.111 Lymphocytic variant hypereosinophilic syndrome
[LHES]
D72.118 Other hypereosinophilic syndrome
D72.119 Hypereosinophilic syndrome [HES], unspecified
D72.12 Drug rash with eosinophilia and systemic
symptoms syndrome
D72.18 Eosinophilia in diseases classified elsewhere
D72.19 Other eosinophilia

Hypereosinophilic syndromes (HES) are a clinically and
pathogenically distinct group of disorders characterized by a sustained
elevated blood eosinophil count and eosinophil-mediated end-organ
damage. The associated eosinophil-induced organ damage or tissue
infiltration is commonly seen in tissues of the cutaneous, pulmonary,
gastrointestinal, cardiac, and nervous systems.
Lymphocytic variant hypereosinophilic syndrome (LHES) is

defined by the presence of clonal or aberrant T lymphocytes that
overproduce Th2 cytokines (such as interleukin-5) that drive blood
and tissue hypereosinophilia. It commonly affects the skin and has the
potential to progress to lymphoma. Corticosteroid and off-label use of
biologic or other immunosuppressive therapy are the main treatments.
Drug rash with eosinophilia and systemic symptoms (DRESS)

syndrome is a rare drug-induced hypersensitivity reaction that
produces a widespread skin rash, fever, lymphadenopathy,
hematological findings (eosinophilia, leukocytosis, etc.) and abnormal
liver function tests. Hepatitis, pneumonitis, myocarditis, pericarditis,
nephritis and colitis, are associated with this form. There is a mortality
rate of 10%. Anticonvulsant drugs, antibiotics and allopurinol appear
to be the predominant cause of DRESS with a delay of 2-8 weeks of
time between drug exposure and onset of the syndrome. There may
be a relapse of symptoms 3-4 weeks after stopping the medication.
Idiopathic hypereosinophilic syndrome (IHES) accounts for 70%

of HES of which there is no known cause. It affects the heart, lung
and central and peripheral nervous systems. Secondary causes of
hypereosinophilia such as allergic, parasitic, and non-hematological
malignant disorders must be excluded to make the diagnosis.
Systemic corticosteroids are the first line of treatment.
Question:
A patient was seen due to dysphagia with
chest and abdominal discomfort. The provider
performed an esophagogastroduodenoscopy
with biopsies. Heavy eosinophilic infiltration
and furrows were seen on the esophageal
mucosa. Eosinophilic esophagitis was the final
diagnosis. How is eosinophilic esophagitis
coded?

Answer:
Assign code K20.0 Eosinophilic esophagitis,
for eosinophilic esophagitis. It would not
be appropriate to assign code D72.18,
Eosinophilia in diseases classified elsewhere,
as eosinophilic esophagitis is specifically
indexed to code K20.0 and the code already
identifies both the esophagitis and the
eosinophilia.
Question:
A patient was seen by the provider because
of fatigue, night sweats, and arthralgia. Skin
nodules of the left leg were seen on physical
examination. Laboratory testing showed
a high eosinophil count and the provider
confirmed a diagnosis of lymphocytic variant
hypereosinophilic syndrome. What is the
diagnosis code assignment for this encounter?
Answer:
Assign code D72.111, Lymphocytic variant
hypereosinophilic syndrome [LHES], for this
syndrome.
Immunodeficiency Status
New codes were created to report specific causes for a patient’s

immunocompromised state. An immunocompromised state refers
to the weakened condition of an individual’s immune system that
makes it less able to fight infections and other diseases. Treating a
patient who is immunocompromised poses more risks and challenges;
therefore, it is important to identify a patient with this status.
Code D84.821, Immunodeficiency due to drugs, was created

for immunodeficiency due to medications that interfere with the
immune system. These medications include but are not limited to
immunosuppressants, corticosteroids and chemotherapy. Code
D84.822, Immunodeficiency due to external causes, was created
for immunodeficiency caused by external factors such as exposure
to radiation therapy or due to bone marrow transplant. Code D84.81,
Immunodeficiency due to conditions classified elsewhere, was
created for an immunocompromised state due to a specific medical

condition such as HIV, AIDS, certain cancers and genetic disorders
that are classified elsewhere in ICD-10-CM. Code D84.89, Other
immunodeficiencies, is for immunodeficiency due to other causes.
Multiple codes may be assigned to show immunodeficiency due

to multiple causes (e.g., cancer and antineoplastic medication). In
cases where the cause of the immunosuppression is not clearly
documented, query the provider.
Question:
A patient was seen in the emergency
department for cellulitis of two fingers on
her right hand. She was admitted to start
intravenous antibiotics due to having an
immunocompromised state caused by
immunosuppressant medication that she takes
for systemic lupus erythematosus (SLE). What
are the appropriate code assignments for the
admission?
Answer:
Assign code L03.011, Cellulitis of right finger,
as the principal diagnosis. Assign codes M32.9,
Systemic lupus erythematosus, unspecified,
for SLE, D84.821, Immunodeficiency due
to drugs, and Z79.899, Other long-term
(current) drug therapy, for the patient’s
immunosuppressed state due to long-term use
of immunosuppressants.
In this case, the immunosuppressant

medication was prescribed by the provider
to suppress the patient’s immune system. An
adverse effect code is not assigned when the
medication has achieved its intended result
in lowering the patient’s immune response to
systemic lupus erythematosus.
Question:
A patient with multiple myeloma was seen for
ear pain and cold symptoms due to acute otitis
media of the left ear and acute viral bronchitis.
The provider documented that the patient is

immunosuppressed due to current long-term
chemotherapy. What are the appropriate code
assignments for this encounter?
Answer:
Sequence either code J20.8, Acute bronchitis
due to other specified organisms, or code
H66.92, Otitis media, unspecified, left ear,
as the first-listed diagnosis. Assign codes
D84.821, Immunodeficiency due to drugs, for
the patient’s immunosuppressed state as a
result of chemotherapy, and T45.1X5A, Adverse
effect of antineoplastic and immunosuppressive
drugs, initial encounter. In this case, the
immune suppression is not part of the intended
effect of the antineoplastic drugs, and is coded
as an adverse effect. Additionally, assign
codes C90.00, Multiple myeloma not having
achieved remission, for the multiple myeloma
and Z79.899, Other long term (current) drug
therapy, for the chemotherapy.
Cytokine Release Syndrome
Codes have been created for cytokine release syndrome (CRS) that
distinguish grades of severity. CRS and cytokine storm syndrome
(CSS) are used synonymously in literature. CRS is a systemic
inflammatory response to infections and certain immunotherapies,
such as monoclonal antibodies and chimeric antigen receptor
(CAR) T-cell therapy that cause activation of the immune system.
Lymphocytes and/or myeloid cells cause a massive and rapid release
of cytokines into the blood. Cytokines are small proteins that act as
cell messengers to help direct the body’s immune response. The
reaction to the cytokine release ranges from mild symptoms to life-
threatening organ failure and death.
At the present time, there are several different systems to grade CRS
with slight variations, including a consensus definition developed
by the American Society for Transplantation and Cellular Therapy
(ASTCT) in 2018. The information below regarding the CRS grades
from the ASTCT scale is provided for informational purposes only and
should not be assumed to be clinical criteria nor an endorsement of

a specific CRS grading system. For ICD-10-CM coding purposes, the
code for the specific CRS grade should be assigned on the basis of
explicit provider documentation of the grade; otherwise the code for
unspecified grade should be assigned.
Grade 1 CRS (D89.831) includes low grade fever with or without

constitutional symptoms (e.g., nausea, headache and myalgia).
Grade 2 CRS (D89.832) is a moderate reaction that includes fever

with hypotension not requiring vasopressors and/or hypoxia requiring
the use of oxygen delivered by low-flow nasal cannula (≤6 L/minute)
or blow-by.
Grade 3 CRS (D89.833) includes fever with hypotension requiring

one vasopressor with or without vasopressin and/or hypoxia requiring
high-flow nasal cannula (>6 L/minute), facemask, nonrebreather
mask, or venturi mask not attributable to any other cause.
Grade 4 CRS (D89.834) includes fever with hypotension requiring

multiple vasopressors (excluding vasopressin) and/or hypoxia
requiring positive pressure (e.g., CPAP, bilevel positive airway
pressure, intubation, mechanical ventilation) not attributable to any
other cause. Irrespective of total cumulative dose, the use of multiple
vasopressors constitutes grade 4 CRS.
Grade 5 CRS (D89.835) is defined as death due to CRS.
Unspecified CRS is assigned to code D89.839.
The risk for CRS is highest in the first two weeks after immunotherapy.
It can occur within minutes to hours after the start of infusion. Factors
such as the underlying disease, whether immunotherapy was
administered for the first time (first-dose effect), drug dosage, and the
magnitude of immune cell activation, influence the severity of CRS.
The most severe symptoms occur after the first administered dose
and may not recur after subsequent administrations.
Additionally, at the time of publication, more and more clinical data

suggest evidence of mild or severe CRS in severe COVID-19 patients.
Therefore, treatment of the cytokine storm has become an important
part of rescuing severe COVID-19 patients.

Question:
A patient with known refractory multiple
myeloma and recent stem cell transplant was
admitted with fever and feeling very drowsy.
Further examination revealed tachycardia,
leukocytosis and hypotension. The provider
diagnosed cytokine release syndrome (CRS),
grade 2, and toxic encephalopathy due to
stem cell transplant. What are the appropriate
diagnosis code assignments for the admission?
Answer:
Assign code T86.5, Complications of stem cell
transplant, as principal diagnosis for the stem
cell transplant complications. Assign codes
G92, Toxic encephalopathy, and D89.832,
Cytokine release syndrome, grade 2, for the
conditions caused by the stem cell transplant.
Code C90.00, Multiple myeloma not having
achieved remission, is assigned for the multiple
myeloma.
Question:
The patient was admitted for treatment of
cytokine release syndrome (CRS), grade 3,
due to COVID-19. What is the appropriate
sequencing for this admission?
Answer:
Assign code U07.1, COVID-19, as the principal
diagnosis. Assign code D89.833, Cytokine
release syndrome, grade 3, as an additional
diagnosis. This sequencing is supported by
the instructional note at subcategory D89.83,
Cytokine release syndrome, to code first the
underlying cause.
Question:
A patient with refractory B cell acute
lymphoblastic leukemia underwent chimeric
antigen receptor (CAR) T-cell therapy and
subsequently developed cytokine release

syndrome (CRS), grade 2. What are the
appropriate codes for this admission/
encounter?
Answer:
Assign code T80.89XA, Other complications
following infusion, transfusion and therapeutic
injection, initial encounter; followed by
code D89.832, Cytokine release syndrome,
grade 2, for CRS grade 2 due to CAR T-cell
administration. In addition, assign code C91.00,
Acute lymphoblastic leukemia not having
achieved remission, for the refractory B cell
acute lymphoblastic leukemia.
Aromatic L-Amino Acid Decarboxylase Deficiency
Code E70.81, Aromatic L-amino acid decarboxylase deficiency,

was created for aromatic L-amino acid decarboxylase (AADC)
deficiency, a rare inherited condition that affects the production of
signals that allow cells in the nervous system to communicate with
one another. The AADC enzyme takes part in the pathway that
produces the neurotransmitters, dopamine and serotonin. Dopamine
is responsible for cognitive function, voluntary movement, and
emotions. Serotonin serves to regulate basal function, mood, sleep,
memory and learning, body temperature, and cardiovascular and
endocrine functions. In addition, code E70.89, Other disorders of
aromatic amino-acid metabolism, has been created.
Symptoms present in the first year of life when there are delays in
walking, talking, muscle stiffness and involuntary writhing movements
of the limbs. AADC deficiency can also affect the autonomic nervous
system and reduce the ability to control body temperature, blood
sugar and blood pressure. The spectrum of AADC deficiency is broad
and symptoms range from mild to severe but the symptoms are not
expected to deteriorate with age.
There is no cure for AADC deficiency. Early diagnosis is critical to

initiate the use of medications to treat symptoms and to replace
and further prevent dopamine and serotonin deficiencies. Physical,
occupational, and speech therapies help manage any decline in motor
function.

An ICD-10-PCS procedure code, for a new gene therapy for treatment
of AADC deficiency has been created. Please refer to page 73 of this
issue of Coding Clinic for additional information.
Glucose Transporter Deficiencies
Codes have been created for deficiencies in glucose transport:
• E74.810 Glucose transporter protein type 1 deficiency

• E74.818 Other disorders of glucose transport
• E74.819 Disorders of glucose transport, unspecified
• E74.89 Other specified disorders of carbohydrate
metabolism
Glucose transporter protein type 1 deficiency syndrome (Glut1DS) is

a genetic disorder that impairs the nervous system and affects brain
metabolism, growth and function. The protein, GLUT1, is responsible
for transporting glucose across the blood-brain barrier and into the
cells of the brain. Mutation in the SCL2A1 gene, that is responsible
for instructions to produce GLUT1, causes a shortage of glucose. The
symptoms of Glut1DS are a result of decreased glucose transport into
the brain.
Glut1DS is an epileptic encephalopathy that is associated with

progressive psychomotor dysfunction. Glut1DS symptoms vary
among individuals; however, seizures are the most common
symptom. Children may start having seizures in the first months
of life up through age 4. Other symptoms include abnormal eye-
head movements, poor balance and muscle tone, slurred speech,
language impairment, intellectual disabilities and microcephaly. Some
individuals experience paroxysmal exercise-induced dyskinesia where
prolonged exercise such as walking or running long distances causes
abnormal involuntary movements.
Withdrawal Syndrome in Substance Use and Abuse
Codes were created for withdrawal in psychoactive substance

use and abuse, which can cause physiological addiction and have
potential for development of withdrawal syndrome when a person
reduces or ceases use of the substance.

The new codes identify withdrawal for the substances and patterns of
use noted below:
• Opioid abuse with withdrawal (F11.13)

• Cannabis abuse with withdrawal (F12.13)
• Cocaine abuse, unspecified with withdrawal (F14.13)
• Cocaine use, unspecified with withdrawal (F14.93)
• Other stimulant abuse with withdrawal (F15.13)
In addition, new codes identify uncomplicated withdrawal, withdrawal

delirium, withdrawal with perceptual disturbance and unspecified
withdrawal for the substances and patterns of use noted below:
• Alcohol abuse (F10.13-)

• Alcohol use (F10.93-)
• Sedative, hypnotic or anxiolytic abuse (F13.13-)
• Other psychoactive substance abuse (F19.13-)
Substance withdrawal can occur in clinical situations involving

individuals who do not have a diagnosis of substance dependence but
use substances regularly and then suddenly stop using them. Such
situations include (1) individuals who are physiologically addicted
to a substance but do not have the behavioral elements required
for a diagnosis of substance dependence when taking a prescribed
medication as directed; and (2) individuals with a diagnosis of
substance abuse who lack the loss of control required for a diagnosis
of substance dependence.
Previously, it was believed that withdrawal syndrome only developed

clinically in individuals with substance dependence.
Friedreich Ataxia
Code G11.11, Friedreich ataxia, was created for Friedreich ataxia

(FA or FRDA). Codes G11.10, Early-onset cerebellar ataxia,
unspecified, and G11.19, Other early-onset cerebellar ataxia,
were created for unspecified and certain other early-onset cerebellar
ataxias.
FA is a genetic neurological disorder that causes progressive

symptoms of gait and balance instability, impaired coordination of
muscles, dysarthria-causing impaired speech, scoliosis, loss of

sensation of the limbs, hypertrophic cardiomyopathy and loss of
hearing and vision. Although FA is rare, it is the most common cause
of hereditary ataxia.
When a region of the FXN gene repeats a GAA segment more than
66-1000 times instead of 5-33 times, it can cause severe damage to
the cerebellum and spinal cord. Nerve fibers in the spinal cord and
peripheral nerves degenerate and cause impaired sensory function
and unsteady movements. The age at which symptoms appear,
severity of symptoms, and how quickly they progress, could be
related to the length of the GAA trinucleotide repeat. FA presents in
most people between the ages of 10 to 16 years, although symptoms
may start as early as age 5 or later, after the age of 25. Patients are
generally confined to a wheelchair within 10 to 20 years after the
appearance of the first symptoms. They are completely incapacitated
in later stages of the disease.
There is no cure for FA. Treatment of symptoms requires a multi-

specialty approach utilizing medication, surgery for orthopedic
deformities, and speech and physical therapies.
Cyclin-Dependent Kinase-Like 5 Deficiency Disorder
Code G40.42, Cyclin-Dependent Kinase-Like 5 Deficiency

Disorder, was created to identify a developmental epileptic
encephalopathy that is caused by mutations in the cyclin-dependent
kinase-like 5 (CDKL5) gene. The CDKL5 gene provides instructions
for making a protein that is essential for normal brain and neuron
development. A deficiency of CDKL5 reduces the amount of functional
CDKL5 protein or alters its activity in neurons.
The hallmark of CDKL5 deficiency disorder is the onset of seizures

at a very young age that are severe and difficult to control with
medication. There are neurodevelopmental impairments that
cause delays in cognitive, motor, speech and visual function. A
child may have limited ability to walk or speak, lack eye contact
and hand coordination. CDKL5 deficiency disorder also causes
autonomic problems and gastrointestinal dysfunction that range
from oral adversity, swallow dysfunction, gastroesophageal reflux
and constipation. Over time, affected children can develop scoliosis.
Treatment of the patient requires a multidisciplinary approach

that includes anticonvulsant medication, physical, occupational,
behavioral, and speech and augmentative communication therapy to
maximize the patient’s abilities.
Dravet Syndrome
Two new codes have been created to identify Dravet syndrome,

intractable, with status epilepticus (G40.833) and without status
epilepticus (G40.834).
Dravet syndrome is a rare genetic encephalopathy that presents in the

first year of life. It was previously known as severe myoclonic epilepsy
in infancy and represents approximately 7% of all severe epilepsies
starting before the age of three years. During the first year of life,
the condition appears as frequent febrile seizures. As the condition
progresses, typically other types of seizures, including myoclonus
and status epilepticus, occur. Around the age of two years, intellectual
development begins to deteriorate and affected individuals often have
a lack of coordination, poor development of language, hyperactivity,
and difficulty relating to others.
Congenital Myopathies
Codes have been created for congenital myopathies as follows:

G71.20, Congenital myopathy, unspecified; G71.21, Nemaline
myopathy; G71.220, X-linked myotubular myopathy; G71.228,
Other centronuclear myopathy; and G71.29, Other congenital
myopathy.
The congenital myopathies are a group of muscle disorders with onset

generally at birth or in infancy. These typically cause weakness, with
poor muscle tone or floppiness, difficulty breathing or feeding, and
lagging behind in meeting normal developmental milestones such as
turning over or sitting up.
The congenital myopathies have traditionally been grouped broadly

based on histopathological findings from muscle biopsy. These have
specifically included three main groups, based on the presence of
cores (core myopathy), central nuclei (centronuclear myopathy), or
nemaline bodies (nemaline myopathy).

Nemaline myopathy (G71.21) is the most common congenital
myopathy. Infants usually have problems with breathing and feeding.
Weakness can be throughout the body, but particularly involves
proximal muscles such as the face, neck, trunk, and upper arms and
thighs. Later, some skeletal problems may arise, such as scoliosis
(curvature of the spine). There are six types of nemaline myopathy,
which are in order of decreasing severity: severe congenital, Amish,
intermediate congenital, typical congenital, childhood-onset, and
adult-onset. The more severe types generally have earlier age of
onset, and the most severe can cause death in early childhood.
Centronuclear myopathy has two subtypes: X-linked myotubular

myopathy (XLMTM)-(G71.220) and autosomal centronuclear
myopathy (G71.228). The term centronuclear myopathy is generally
used for the autosomal forms of the disorder (both dominant and
recessive), while the term myotubular myopathy is generally used
for the X-linked form, XLMTM. Distinguishing between XLMTM and
the autosomal forms is essential, as the symptoms are usually more
severe in XLMTM. XLMTM is rare, and occurs almost exclusively
in males. In XLMTM, weakness and floppiness are so severe that
a mother may notice reduced movements of the baby in her womb
during pregnancy. Infants with XLMTM are typically born with severe
muscle weakness and decreased muscle tone, with the majority
requiring chronic mechanical ventilation from birth. There is no
approved specific treatment for XLMTM, and disease management
now is primarily supportive.
Autosomal centronuclear myopathy is rare, but the prevalence

is unknown. It usually begins in infancy or early childhood with
weakness of the arms and legs (which often gets worse with time),
droopy eyelids, and problems with eye movements. Onset can also
be later, even to early adulthood. Centronuclear myopathy is most
often inherited in an autosomal dominant fashion, or more rarely as a
recessive trait.
The core myopathies (G71.29): central core disease and multi-

minicore disease, are both thought to be uncommon or rare, although
the incidence is not known. Central core disease varies in the severity
of problems and the degree of worsening over time; usually, there
is mild floppiness in infancy, delayed milestones, and moderate
limb weakness, which do not worsen much over time. Children with
central core disease may have life-threatening reactions of malignant
hyperthermia to general anesthesia.

Multi-minicore disease has several different subtypes, with most
causing severe weakness of the limbs and scoliosis. Often breathing
difficulties also occur. Some children have weakened eye movements.
It also may be called minicore disease or multicore disease.
Other congenital myopathies (G71.29), which include congenital

fiber-type disproportion myopathy and myosin storage myopathy, are
rare and do not have known incidence rates. Congenital fiber-type
disproportion (CFTD) myopathy begins with floppiness, limb and facial
weakness, and breathing problems. Myosin storage myopathy is
primarily characterized by muscle weakness with minimal or very slow
progression.
These specific ICD-10-CM codes will enable improved tracking of

these disorders, as well as enabling easier assessment of cases
where there are associated diagnoses present, and where particular
procedures are necessary related to a specific diagnosis.
Cerebrospinal Fluid Leak
The following new codes have been created to describe cranial and
spinal cerebrospinal fluid leaks:
• G96.00 Cerebrospinal fluid leak, unspecified

• G96.01 Cranial cerebrospinal fluid leak, spontaneous
• G96.02 Spinal cerebrospinal fluid leak, spontaneous
• G96.08 Other cranial cerebrospinal fluid leak
• G96.09 Other spinal cerebrospinal fluid leak
There is also a new “code also, if applicable: intracranial hypotension

(G96.81-)” note at subcategory G96.0, Cerebrospinal fluid leak.
Cerebrospinal fluid leak (CSF) occurs when there is a tear or hole
in the membranes surrounding the brain or spinal cord, allowing
the clear fluid that surrounds and cushions those organs to escape.
Cranial CSF leaks occur in the head and are associated with CSF
rhinorrhea, in which the cerebrospinal fluid escapes through the nasal
passages (runny nose), salty or metallic taste in the mouth, a sense
of drainage down the back of the throat and loss of sense of smell
(anosmia). Spinal CSF leaks develop due to tears in the soft tissues
surrounding the spinal cord. Common symptoms include: positional
headache, nausea and vomiting, neck pain or stiffness and a sense of
imbalance.

Loss of cerebrospinal fluid may result in intracranial hypotension.
Intracranial hypotension is most often associated with a CSF leak at
the level of the spine and is not causally associated with a CSF leak
arising from the skull base.
CSF leaks may occur spontaneously and the cause is unknown.

Other CSF leaks are the result of trauma such as head injury, brain or
spinal surgery, an epidural, a lumbar puncture (spinal tap) or a skull
base tumor.
It is clinically important to differentiate between spontaneous CSF

leaks and other CSF leaks, and between cranial CSF leaks and spinal
CSF leaks.
New codes were created to enable better differentiation of cranial

and spinal cerebrospinal fluid leaks, which have different underlying
causes, symptoms, complications, diagnostic testing and treatments.
Perineural Cyst
Code G96.19, Other disorders of meninges, not elsewhere classified,

has been expanded and two new codes have been created:
• G96.191 Perineural cyst
• G96.198 Other disorders of meninges, not elsewhere
classified
The codes will allow the unique identification of perineural cysts,

also called Tarlov cysts. Perineural cysts are cerebrospinal fluid-
filled sacs that affect nerve roots of the cervical, thoracic, lumbar and
sacral spine, but are more common near the sacral region. The cysts
can compress adjacent nerve roots or nerves contained within the
cyst and cause a variety of symptoms depending on the cyst size
and location. Symptoms include lower back pain, sciatica, urinary
incontinence, headaches, constipation, sexual dysfunction, and some
loss of feeling or control of movement in the leg and/or foot.
Perineural cysts can be diagnosed using magnetic resonance imaging

(MRI); however, it is estimated that the majority of the cysts observed
by MRI cause no symptoms. There is some clinical evidence that
symptoms develop following shock, trauma, or exertion, causing
a buildup of cerebrospinal fluid and possible connective tissue
disorders. Women are at much higher risk of developing these cysts.

Intracranial Hypotension
A new subcategory, G96.81, Intracranial hypotension, has been

created with three new codes to uniquely identify unspecified
intracranial hypotension (G96.810), spontaneous intracranial
hypotension (G96.811), and other intracranial hypotension (G96.819).
In addition, a new code has been created for other specified disorders
of central nervous system (G96.89).
Subcategory G97.8, Other intraoperative and postprocedural

complications and disorders of nervous system, has also been
expanded and two new codes were created to identify intracranial
hypotension following lumbar cerebrovascular fluid shunting (G97.83)
and intracranial hypotension following other procedure (G97.84).
When serious complications occur as a result of intracranial
hypotension, such as subdural hematomas, stroke, cerebral venous
thrombosis, fronto-temporal dementia, or syringomyelia, these
conditions should also be coded. The sequencing depends on the
circumstances of the encounter as indicated by the “Code also any
associated diagnoses” Tabular List instruction at subcategory G96.81,
Intracranial hypotension.
Intracranial hypotension is an under-recognized and under-diagnosed

central nervous system disorder resulting from a loss of cerebrospinal
fluid volume. Intracranial hypotension is most often associated with
a cerebrospinal fluid leak at the level of the spine and is not causally
associated with cerebrospinal fluid leaks arising from the skull base.
For a list of common causes of CSF leak, please refer to page 21 of
this issue of Coding Clinic.
The causes of intracranial hypotension include:
• Spontaneous cerebrospinal fluid leaks at the level of the spine

(most under-recognized category)
• Iatrogenic holes or defects in the spinal dura from:
o Intentional diagnostic or therapeutic spinal dural punctures

o Inadvertent spinal dural puncture during epidural injection
procedures
o Inadvertent or intentional spinal durotomies during spinal or
other surgeries

• Over-drainage of cerebrospinal fluid shunting devices
• Traumatic spinal dural tears or defects resulting in spinal
cerebrospinal fluid leaks.
Question:
A 35-year-old woman was admitted with a
two-month history of headaches, occasionally
accompanied by nausea, vomiting, and
vertigo. The chronic daily headache is worse
in the upright position, but gets better when
lying down. She also had a negative history
of lumbar puncture, trauma, or manipulation.
Magnetic resonance imaging (MRI) showed
meningeal enhancement. She was discharged
with the diagnosis of positional headache
due to spontaneous intracranial hypotension.
What is the appropriate code assignment
for positional headache due to spontaneous
intracranial hypotension?
Answer:
Assign code G96.811, Intracranial hypotension,
spontaneous, for the diagnosis of positional
headache due to spontaneous intracranial
hypotension. No additional code for the
headache should be assigned, as it is a
common symptom of intracranial hypotension.
Hereditary Corneal Dystrophy
The codes in subcategory H18.5, Hereditary corneal dystrophies,

have been expanded to identify laterality (i.e., right eye, left eye,
bilateral and unspecified eye). This change results in 28 new codes.
While the dystrophies are generally thought to be bilateral conditions,
they may be asymmetric and may not require the same interventions.
The ability to report laterality is important for tracking outcomes.
Corneal dystrophy is a group of rare genetic eye conditions in which
one or more parts of the cornea lose their normal clarity due to
abnormal deposition of substances.

Irregular Eye Movement
Code H55.81 was revised to “Deficient saccadic eye movements,”

and code H55.82, Deficient smooth pursuit eye movements, was
created to describe irregular eye movements.
Smooth pursuit eye movements permit the eyes to follow a moving

object closely. It is one of two ways, in which people can shift gaze.
Saccades are rapid eye movements that bring the image of an object
of interest onto the fovea and is another method of shifting gaze.
Deficient smooth pursuit eye movements (smooth pursuit deficiency)
are disorders involving the impairment of eye movements. Saccadic
disorders may result in abnormal latency to initiate eye movements,
abnormal speed of eye movements (generally slow), or abnormal
accuracy of eye movements (hypometria or hypermetria). The specific
type of abnormality relates to the pattern of neural activity delivered to
the ocular motor neurons.
Previously, deficient smooth pursuit eye movements was reported

using code H55.89, Other irregular eye movement. These changes
were made to allow for more precise reporting of these conditions,
which will help to facilitate research and public health.
Pulmonary Eosinophilic Diseases
New subcategory J82.8, Pulmonary eosinophilia, not elsewhere

classified, has been created with unique codes to identify certain
pulmonary eosinophilic diseases. These new codes describe chronic
eosinophilic pneumonia (J82.81), acute eosinophilic pneumonia
(J82.82), eosinophilic asthma (J82.83), and other pulmonary
eosinophilia, not elsewhere classified (J82.89).
There are two types of eosinophilic pneumonia, acute and chronic.

While both are characterized by eosinophil invasion of the lung
tissue, the clinical presentation is quite different. Acute eosinophilic
pneumonia (AEP) is classified as a form of eosinophilic lung disease,
one of a large group of interstitial lung diseases. AEP typically
involves rapidly progressive respiratory failure, which may lead to
the need for intensive care and mechanical ventilation. Radiologic
imaging usually shows abnormalities throughout the lung fields.
Finding eosinophils in lung washings from bronchoalveolar lavage

(BAL) is key in the diagnosis of AEP. BAL fluid in individuals with AEP
reveals abnormally high levels of eosinophils (greater than 25%).
Associated symptoms are nonspecific and can include fever,
cough, difficulty breathing (dyspnea) and chest pain. Less common
symptoms include fatigue, muscle pain (myalgia), joint aches,
and abdominal discomfort or pain. The disease is responsive to
corticosteroids. Although the etiology of AEP is idiopathic, it has been
noted to be associated with new onset of cigarette smoking or an
increase in smoking. Other cases of AEP in the literature include a
series on U.S military personnel in Iraq and another on September 11,
2001 rescue workers exposed to dust from the World Trade Center.
Chronic eosinophilic pneumonia (CEP) is different from AEP. CEP
is a chronic, indolent condition that is characterized by progressive
shortness of breath and abnormalities on chest imaging, in the
periphery of the lungs. Bronchoscopy with the finding of increased
eosinophils on airway washings confirms the diagnosis. Common
symptoms include shortness of breath (dyspnea), cough, fatigue,
night sweats, low-grade fevers, and unintended weight loss.
Symptoms can be very similar to those seen in asthma, including the

development of wheezing. Treatment consists of a prolonged course
of corticosteroids. The exact cause of chronic eosinophilic pneumonia
is unknown, but researchers believe that CEP may develop due to
an unidentified, nonspecific triggering agent that causes the body to
produce excess eosinophils. CEP can recur, and patients will relapse
if therapy is not maintained. Some patients will develop severe
asthma.
Eosinophilic asthma is a subtype of asthma that is more severe, and

typically occurring in patients who develop asthma in adulthood,
although it may occur in children and young adults. This new
subset is based on immune mechanisms underlying asthma, which
is characterized by the presence of eosinophils in the circulation
and in the airways. In the United States, an estimated 25.7 million
individuals have some form of asthma. Approximately 15 percent
of these persons have severe asthma that is difficult to control with
standard medications. Eosinophilic asthma can be difficult to treat
and may have a detrimental effect on an individual’s quality of life,
because it does not respond well to corticosteroids. The Food and
Drug Administration (FDA) has approved several biologic treatments
for eosinophilic asthma, and in clinical trials these novel therapies
have proven to be beneficial. These new drugs specifically target

eosinophils by blocking a molecule known as IL-5 or its receptor.
These drugs also reduce asthma exacerbations regardless of the
cause.
ICD-10-CM codes classify asthma based on severity, persistence, and

the presence of exacerbation. When assigning a code for eosinophilic
asthma, the type of asthma is sequenced first, such as moderate
persistent asthma. For example:
Question:
An adult patient presents with symptoms of
wheezing, coughing, shortness of breath/
difficulty breathing, inflamed nasal mucous
membrane and chest tightness. Following
diagnostic work-up, the provider diagnosed
acute exacerbation of severe persistent
eosinophilic asthma. What is the correct code
assignment for an exacerbation of severe
persistent eosinophilic asthma?
Answer:
Assign codes J45.51, Severe persistent
asthma with (acute) exacerbation, and
J82.83, Eosinophilic asthma, for an acute
exacerbation of severe persistent eosinophilic
asthma. Eosinophilic asthma is associated
with increased asthma severity and both codes
are needed to fully capture the diagnostic
statement.
Progressive Fibrotic Interstitial Lung Disease
Code J84.17, Other interstitial pulmonary diseases with fibrosis in

diseases classified elsewhere, has been expanded with new codes
to identify interstitial lung disease (ILD) with progressive fibrotic
phenotype in diseases classified elsewhere. The new codes are as
follows.
J84.170 Interstitial lung disease with progressive

fibrotic phenotype in diseases classified
elsewhere

J84.178 Other interstitial pulmonary diseases with
fibrosis in diseases classified elsewhere
ILD encompasses a large group of pulmonary disorders. Although

the ILDs are heterogeneous in etiology, pathophysiology and clinical
course, the major abnormality in ILDs is disruption of the distal lung
parenchyma. While the pathogenesis remains unknown, especially
for idiopathic interstitial pneumonias (IIPs), it is generally agreed
that some form of injury of the alveolar epithelial cells initiates an
inflammatory response coupled with repair mechanisms. The injury-
repair process is reflected pathologically as inflammation, fibrosis
or a combination of both. The resulting alteration of the interstitial
space leads to clinical symptoms, including dyspnea, cough, and
physiologic abnormalities consistent with restrictive ventilatory deficit
on pulmonary function testing.
Some patients with certain types of ILD, including chronic

hypersensitivity pneumonitis and ILDs associated with autoimmune
diseases, develop a progressive fibrosing phenotype that
demonstrates similarities in clinical course to idiopathic pulmonary
fibrosis. Progressive fibrosing ILDs are characterized by a decline in
lung function, worsening of symptoms and health-related quality of
life, and early mortality.
While there is limited data in the literature on this patient subgroup,

the scientific working hypothesis is that the response to lung injury
in these ILDs includes the development of fibrosis, which becomes
progressive, self-sustaining and independent of the original clinical
association or trigger. These patients are considered to represent a
distinct phenotype.
The new codes will allow data collection to help provide a clearer
picture of the clinical course and impact of progressive fibrosing ILDs.
Esophagitis
Several new codes have been created to describe other esophagitis,

unspecified esophagitis, and gastroesophageal reflux disease with
esophagitis. These new codes also identify whether there is bleeding
involved as follows:

K20.80 Other esophagitis without bleeding
K20.81 Other esophagitis with bleeding
K20.90 Esophagitis, unspecified without bleeding
K20.91 Esophagitis, unspecified with bleeding
K21.00 Gastro-esophageal reflux disease with esophagitis,
without bleeding
K21.01 Gastro-esophageal reflux disease with esophagitis,
with bleeding
Esophagitis is an inflammation of the lining of the esophagus and

can be caused by an infection or irritation. Gastroesophageal reflux
disease (GERD) occurs when stomach acid flows back into the
esophagus and may also cause esophagitis. Other causes include,
but are not limited to infection, medication, and allergies. If untreated,
esophagitis can lead to bleeding, ulceration, and chronic scarring.
These new codes were created to reflect the presence of bleeding.
The codes will assist in describing the difference in severity. The
American Gastroenterological Association (AGA) supports the
creation of these new codes.
Ogilvie Syndrome
Code K59.8, Other specified functional intestinal disorders, has been

expanded with new codes to describe Ogilvie syndrome (K59.81) and
other specified functional intestinal disorders (K59.89).
Ogilvie syndrome, also referred to as acute colonic ileus and acute

colonic pseudo-obstruction (ACPO), is an uncommon condition that
affects the large intestines. Ogilvie syndrome is not the same as
chronic intestinal pseudo-obstruction.
The syndrome is due to nerve or muscle problems that affect

peristalsis (involuntary, rhythmic muscular contractions) within the
colon. Although the symptoms mimic those of mechanical blockage
of the colon, no such physical obstruction is present. Symptoms of
Ogilvie syndrome are similar to other forms of intestinal pseudo-
obstruction and can involve nausea and vomiting, abdominal pain,
diarrhea, and constipation. Distention of the colon can be life
threatening, leading to perforation of the colon and lack of blood flow
to the colon. If untreated, this syndrome can result in malnutrition,
bacterial overgrowth in the colon, and weight loss.

The underlying etiology of Ogilvie syndrome is not known. However,
it is typically seen in adults after surgery when the colon becomes
enlarged and following illness or injury. Treatment options include
supportive care that addresses associated symptoms, medications,
decompression, and surgery.
Hepatic Fibrosis
Code K74.0, Hepatic fibrosis, has been expanded, with specific codes
to identify unspecified hepatic fibrosis, as well as early and advanced
hepatic fibrosis. The new codes are as follows:
• K74.00 Hepatic fibrosis, unspecified

• K74.01 Hepatic fibrosis, early fibrosis
• K74.02 Hepatic fibrosis, advanced fibrosis
Hepatic fibrosis occurs when healthy liver tissue becomes scarred.

Fibrosis is the first stage of liver scarring. If the scarring progresses,
hepatic fibrosis can become advanced, resulting in liver cirrhosis
and failure. Nonalcoholic steatohepatitis (NASH) is a condition that
causes fat to build up in the liver, leading to inflammation and fibrosis.
NASH is part of the broader spectrum of nonalcoholic fatty liver
disease (NAFLD), distinguished from other NAFLD by the presence of
hepatocyte injury.
Hepatic fibrosis associated with NASH has a classification accepted

by the Food & Drug Administration (FDA) as an endpoint for clinical
trials, in the NASH Clinical Research Network (CRN) staging system.
The NASH CRN classification evaluates fibrosis stage on a scale
from F0 to F4 as follows: F0 – no fibrosis (thus no fibrosis codes
applicable); F1 – perisinusoidal or periportal, and F2 – perisinusoidal
and portal/periportal (early fibrosis, K74.01); F3 – bridging fibrosis
or pre-cirrhosis (advanced fibrosis, code K74.02); and F4 – cirrhosis
(also advanced fibrosis, but coded to subcategory K74.6-). This
staging system is being described for informational purposes only and
does not constitute clinical criteria, nor should it be used for coding
purposes.
ICD-10-CM classifies hepatic fibrosis stages as follows, as noted in

the Tabular List instructions:

• Stage F1 or F2 to code K74.01, Hepatic fibrosis, early fibrosis
• Stage F3 to code K74.02, Hepatic fibrosis, advanced fibrosis,
and
• Stage F4 to subcategory K74.6-, Other and unspecified
cirrhosis of liver.
In the United States, it has been estimated that 16 million adults have
NASH. Of these, about 20% (3.3 million people) have advanced
fibrosis (fibrosis stages F3 or F4). The diagnosis of advanced fibrosis
due to NASH may be delayed, because of lack of awareness,
deficient testing, and the asymptomatic nature of the condition.
In many cases, diagnosis of the disease will be delayed until the
patient reaches end stage liver disease (ESLD). Advanced fibrosis
due to NASH is associated with an increased risk of liver-related
complications, and liver-related mortality. Patients with advanced
fibrosis due to NASH also have a reduced quality of life and a higher
incidence of liver cancer. Traditionally, assessment of hepatic fibrosis
has been via liver biopsy. However, newer non-invasive tests can now
be used for assessment of the stages of hepatic fibrosis.
When the patient is diagnosed with advanced hepatic fibrosis

(K74.02) and liver cirrhosis, assign only code K74.60, Unspecified
cirrhosis of liver. The Excludes1 note at K74.02 prohibits assigning
both codes, K74.02 and a code from subcategory, K74.6, Other and
unspecified cirrhosis of liver, together.
These new codes will allow liver fibrosis to be accurately classified

and consistent with current clinical perspectives. This will enable
enhanced tracking and research into disease progression and the
impact of treatment.
“Other Specified Site” Joint Related Disorders
Twenty-one new codes have been created for several joint related
disorders by adding “other specified site,” or “other specified joint” to
the subcategories listed below. The changes will allow the reporting
of these conditions when they occur in other sites not specified by
existing codes, such as the temporomandibular joint.
M05.7- Rheumatoid arthritis with rheumatoid factor

without organ or systems involvement
M05.8- Other rheumatoid arthritis with rheumatoid factor

M06.0- Rheumatoid arthritis without rheumatoid factor
M06.8- Other specified rheumatoid arthritis
M08.0- Unspecified juvenile rheumatoid arthritis
M08.2- Juvenile rheumatoid arthritis with systemic onset
M08.4- Pauciarticular juvenile rheumatoid arthritis
M08.9- Juvenile arthritis, unspecified
M19.0- Primary osteoarthritis of other joints
M19.1- Post-traumatic osteoarthritis of other joints
M19.2- Secondary osteoarthritis of other joints
M24.1- Other articular cartilage disorders
M24.2- Disorder of ligament
M24.3- Pathological dislocation of joint, not elsewhere
classified
M24.4- Recurrent dislocation of joint
M24.5- Contracture of joint
M24.6- Ankylosis of joint
M24.8- Other specific joint derangements, not elsewhere
classified
M25.3- Other instability of joint
M25.5- Pain in joint
M25.6- Stiffness of joint, not elsewhere classified
Arthritis and Arthropathy of Temporomandibular Joint
The following two new sub-subcategories were created at

subcategory M26.6, Temporomandibular joint disorders, to distinguish
arthritis from arthropathy of the temporomandibular joints.
• M26.64-, Arthritis of temporomandibular joint

• M26.65-, Arthropathy of temporomandibular joint
Sixth characters at each of the new sub-subcategories identify

laterality (i.e., right, left, bilateral and unspecified).
Osteoporosis Related Pathological Fractures
New codes for pathological fracture of “other specified site”

were created for current pathological fracture due to age-related
osteoporosis (M80.0A-) and current pathological fracture due to other
osteoporosis (M80.8A-). The change will allow reporting of current
pathological fractures due to osteoporosis of a site not elsewhere
classified, such as the maxilla, mandible or ribs.

Question:
The patient is an 89-year-old female with
known osteoporosis who fell from bed at the
nursing home with resultant rib fractures. The
provider was queried and confirmed that the rib
fractures were due to osteoporosis due to her
advanced age. How is this coded?
Answer:
Assign code M80.0AXA, Age-related
osteoporosis with current pathological fracture,
other site, initial encounter for fracture, as the
principal diagnosis. In addition, assign codes
W06.XXXA, Fall from bed, initial encounter,
and Y92.122, Bedroom in nursing home, as
the place of occurrence of the external cause,
to identify the external cause of injury and the
location of the patient at the time of injury.
Juvenile Osteochondrosis of Tibia and Fibula
Subcategory M92.5, Juvenile osteochondrosis of tibia and fibula, has

been expanded to distinguish juvenile osteochondrosis of different
parts of the tibia and fibula as follows:
• Unspecified juvenile osteochondrosis (M92.50-)

• Juvenile osteochondrosis of proximal tibia (M92.51-)
• Juvenile osteochondrosis of tibia tubercle (M92.52-)
• Other juvenile osteochondrosis of tibia and fibula (M92.59-)
Sixth characters at each of the codes identify laterality (i.e.,

unspecified leg, right leg, left leg and bilateral).
The code expansion will help to distinguish Blount disease and

Osgood-Schlatter disease. These are two very distinct conditions both
in character, prognosis and treatment.
Blount disease (M92.51-) is a growth disorder of the tibia (shin

bone) resulting in bowlegged appearance. The disease causes the
growth plate near the inside of the knee to either slow down or stop
making new bone, while the growth plate near the outside of the knee
continues to grow normally. Some children may also experience pain

and instability of the knee. This condition occurs in growing children.
Infantile Blount’s disease generally occurs as bilateral deformity only
in the tibia (shin bone). Adolescent Blount’s disease occurs in children
over 10 years of age and is more likely to be unilateral typically
affecting both the femur and the tibia.
Osgood-Schlatter disease (M92.52-) occurs in adolescence and is

characterized by a painful bump just below the knee that is worse
with activity and better with rest. Soreness and swelling at the
tibial tuberosity is also common. It usually occurs in children and
adolescents during puberty, and most often in children who participate
in sports that involve running, jumping and swift changes of direction.
C3 Glomerulopathy
Changes have been made at categories N00 to N07 to identify

glomerular diseases to align with clinical consensus of complement
component 3 (C3) glomerulopathy (C3G) subtypes critical for
identifying appropriate disease etiology, patient segmentation, and
therapeutic selection. The new codes identify C3 glomerulonephritis
(C3GN) with conditions classified to categories N00-N07 as noted
below:
N00.A Acute nephritic syndrome with C3

glomerulonephritis
N01.A Rapidly progressive nephritic syndrome with C3
glomerulonephritis
N02.A Recurrent and persistent hematuria with C3
glomerulonephritis
N03.A Chronic nephritic syndrome with C3
glomerulonephritis
N04.A Nephrotic syndrome with C3 glomerulonephritis
N05.A Unspecified nephritic syndrome with C3
glomerulonephritis
N06.A Isolated proteinuria with C3 glomerulonephritis
N07.A Hereditary nephropathy, not elsewhere classified
with C3 glomerulonephritis
C3G is a newly classified, uncommon renal disorder characterized by

the deposition of C3 within the glomeruli. The major features of C3G
include proteinuria, hematuria, reduced amounts of urine, low levels
of protein in the blood, and swelling in many areas of the body. C3G

is comprised of two distinct clinical subtypes: C3 glomerulonephritis
(C3GN) and dense deposit disease (DDD). While DDD has specific
ICD-10-CM codes, there were no specific codes for C3G or the
subtype C3GN.
Stage 3 Chronic Kidney Disease
Code N18.3, Chronic kidney disease, stage 3 (moderate), has been

expanded to capture additional stage 3 detail and differentiate chronic
kidney disease (CKD) stage 3 unspecified (N18.30), CKD stage 3a
(N18.31), and CKD stage 3b (N18.32).
Current clinical practice for renal function monitoring is to calculate

estimated glomerular filtration rate (eGFR), using inputs of serum
creatinine concentration and several other parameters including
height, weight, gender, and ethnicity. Stage 3 CKD involves an eGFR
between 30 and 59. Stage 3 is further subdivided based on the
eGFR into stage 3a (eGFR between 45 and 59) and Stage 3b (eGFR
between 30 and 44). Code assignment should be based on provider
documentation of the stage.
Granulomatous Mastitis
New subcategory N61.2, Granulomatous mastitis, has been created

with codes to identify whether this condition affects the right breast,
left breast or bilateral breasts. The change will allow the differentiation
of granulomatous mastitis from other types of mastitis currently
identified by ICD-10-CM codes.
Granulomatous mastitis is a rare, chronic, inflammatory condition of

the breast affecting women of child-bearing age. The main symptoms
include a palpable mass, skin or nipple retraction, and pain and
swelling in the breast. The etiology is unknown and there is no
universally accepted treatment to date, but antibiotics, corticosteroids,
drainage, excision, and surgical removal of the lesion have been tried
with variable success.

Maternal Care for Other Type of Scar
from Previous Cesarean Delivery
Unique codes have been created to identify maternal care for other
type of scar from previous cesarean delivery (O34.218) and maternal
care for cesarean scar (isthmocele) defect (O34.22). These new
codes describe non-lower uterine segment scars from previous
cesarean delivery.
Women who have a prior non-lower uterine segment scar, such

as a mid-transverse T incision cesarean scar, are at higher risk of
uterine rupture at the site of the previous uterine scar in subsequent
pregnancies. The surgeon may elect to perform a mid T incision when
additional space is required to deliver the infant. “Mid-transverse T
incision” is an inclusion term under code O34.218.
An isthmocele is a type of cesarean scar defect or niche that develops

at the site of a previous cesarean hysterotomy and is associated
with an increased risk for uterine rupture. Other complications may
include but are not limited to infertility, placenta accrete or previa, scar
dehiscence, and ectopic pregnancy.
Question:
The patient presents for elective cesarean
section. During the last pregnancy, she
had undergone a mid-transverse T incision
cesarean delivery. What is the appropriate
diagnosis code assignment for a patient with
a previous cesarean mid-transverse T incision
scar?
Answer:
Assign code O34.218, Maternal care for other
type scar from previous cesarean delivery.
Other Specified Diseases and Conditions Complicating

Pregnancy, Childbirth and the Puerperium
Code O99.89, Other specified diseases and conditions complicating

pregnancy, childbirth and the puerperium, has been expanded to
allow clinicians and coding professionals to identify the obstetric-

related stage of the patient (i.e., pregnancy, childbirth, puerperium).
This expansion will improve the accuracy and specificity of data
collected during pregnancy, childbirth, and the postpartum period. The
following unique codes have been created with a sixth digit character,
specifying the obstetric-related stage of the patient:
• O99.891 Other specified diseases and conditions

complicating pregnancy
complicating childbirth
complicating puerperium
Neonatal Cerebral Infarction
A new subcategory P91.82, Neonatal cerebral infarction, has been

created with the following codes to describe right, left, bilateral and
unspecified neonatal cerebral infarction:
• P91.821 Neonatal cerebral infarction, right side of brain

• P91.822 Neonatal cerebral infarction, left side of brain
• P91.823 Neonatal cerebral infarction, bilateral
• P91.829 Neonatal cerebral infarction, unspecified side
Neonatal cerebral infarction (or stroke) is a cerebrovascular condition

that occurs between 20 weeks of fetal life through the 28th postnatal
day. This condition is defined as a severe disorganization or even a
complete disruption of the gray matter of the developing brain caused
by embolic, thrombotic or ischemic events.
This disorder results in ischemic and hemorrhagic injury around focal

or multifocal cerebral vessels in which there is disruption of cerebral
blood flow secondary to arterial or cerebral venous thrombosis or
embolization. Neurologic symptoms in the neonatal period can be
nonspecific and not discernible. Common presenting symptoms
include focal motor seizure and/or asymmetric neurologic tone of
the contralateral limb. A neonatal cerebral infarction is confirmed by
neuroimaging or neuropathological studies and is often demonstrated
on computed tomography (CT) scan of the brain or magnetic
resonance imaging (MRI). Diffusion-weighted magnetic resonance
imaging (DWI or DW-MRI) is the most sensitive imaging modality. The

condition is commonly seen in the right or left middle cerebral artery
distribution and is most often unilateral. Laterality is important for
epidemiology, prognosis, and follow-up.
There are several conditions, such as bacterial meningitis, inherited

or acquired coagulopathies, trauma, and hypoxia-ischemia, which
can be responsible for neonatal cerebral infarction in full-term
infants. In many cases, a specific cause cannot be identified.
Neurodevelopmental outcomes in these infants are good, and most
newborns recover complete motor function.
Question:
A newborn infant was delivered at 38 weeks of
gestation via spontaneous vaginal delivery and
initially had a normal physical exam. However,
the baby developed clonic seizures on the right
side of the body. Diffusion-weighted magnetic
resonance imaging (DW-MRI) demonstrated
an abnormality in the left middle cerebral artery
(MCA). The provider diagnosed neonatal
cerebral infarction of the left MCA. How is this
admission coded?
Answer:
Assign code Z38.00, Single liveborn infant,
delivered vaginally, as the principal diagnosis.
Assign code P91.822, Neonatal cerebral
infarction, left side of brain, as an additional
diagnosis. Also assign code P90, Convulsions
of newborn, as a secondary diagnosis.
Headache with Orthostatic Component
Code R51, Headache, has been expanded and two new codes have
been created as noted below:
• R51.0 Headache with orthostatic component, not

elsewhere classified
• R51.9 Headache unspecified
The change will allow the codes to differentiate headaches with an

orthostatic component. These headaches, also known as positional

headache, postural headache or orthostatic headache occur within
30 seconds after assuming the erect posture and subside completely
when the patient lies flat. It is most commonly seen after lumbar
puncture, but it can also be a common symptom of intracranial
hypotension, although not all patients with intracranial hypotension
complain of headaches.
Elevated Liver Enzymes
Code R74.0 Nonspecific elevation of levels of transaminase and lactic

acid dehydrogenase [LDH], has been expanded to separately report
elevation of levels of liver transminase (R74.01) and elevation of
levels of LDH (R74.02). Code R74.01 includes elevation of levels of
alanine transaminase (ALT) and aspartate transaminase (AST).
It’s important to distinguish elevations of different liver enzymes
because they can result in different clinical treatment modalities and
resource utilization.
Superficial Injury of Thorax
Category S20, Superficial injury of thorax, has been expanded and

codes created to separately identify the middle and bilateral walls of
the front thorax (e.g. bilateral front wall, middle front wall) to better
track injuries of these specific sites. Codes already exist for the left,
right, and unspecified front and back walls of the thorax. This change
results in 54 new codes after applying the 7th characters for initial
encounter, subsequent encounter and sequelae for the following
superficial injuries:
• Contusion (S20.2-)
• Unspecified superficial injury (S20.30-)
• Abrasion (S20.31-)
• Blister (S20.32-)
• External constriction (S20.34-)
• Superficial foreign body (S20.35-)
• Insect bite (S20.36-) and
• Other superficial bite (S20.37-)
The anterior thorax is one of the most common locations of traumatic

injury. Blunt trauma is usually to the mid-chest region with high energy
injuries as seen with vehicle collisions being responsible for more than
25% of trauma related deaths.

Synthetic Narcotics
New codes have been created at subcategory T40.4, Poisoning

by, adverse effect of and underdosing of other synthetic narcotics,
to uniquely identify the specific opioids such a fentanyl or fentanyl
analogs (T40.41-), tramadol (T40.42-) and other synthetic narcotics
(T40.49-). The resulting 54 new codes (including the corresponding
7th characters) will support improved surveillance and health services
to inform federal and state-level prevention and intervention programs
to address the current opioid epidemic.
Pharmaceutical fentanyl is a synthetic opioid pain reliever approved

for treating severe pain, typically advanced cancer pain, and is 50 to
100 times more potent than morphine. It is prescribed as transdermal
patches or lozenges. Fentanyl and fentanyl analogues are highly
potent opioids responsible for harm, overdose and death in the
United States posing a serious threat to the public health. Chemically
identical counterfeit fentanyl, as well as carfentanil and other fentanyl
analogs not approved for human use, are sold through illegal drug
markets for their opioid-like effect. They are often combined with
heroin, cocaine, and other substances or mixed with fillers and
pressed into counterfeit opioid pills as a combination product—with or
without the user’s knowledge--to increase its euphoric effect.
Tramadol is an opioid analgesic approved for the treatment of

moderate to moderately severe pain in adults. It has been noted to be
misused causing serious problems, including overdose and death.
Complications of Corneal Transplant
Codes in subcategory T86.84, Complications of corneal transplant,

were expanded with seventh characters to identify laterality (right, left,
bilateral and unspecified). Complications from a corneal transplant
most often apply to a single eye. Properly using eye laterality will help
assist in outcomes and quality assessments.

Electric Scooter and Other Micro-Mobility Devices
External cause of morbidity and mortality codes for Pedestrian Injured

In Transport Accident (categories V00-V06) have been expanded
to separately capture injuries involving standing electric scooters
(e-scooters) and other ultra-light standing micro-mobility devices
from injuries related to other types of pedestrian conveyances. The
expansion results in 123 new diagnosis codes when including the 7th
characters for initial encounter, subsequent encounter and sequelae.
E-scooters have a narrow platform where the rider generally

stands with one foot in front of the other, and travel at speeds up to
approximately 15 miles per hour. Riders may operate their vehicles
in a variety of spaces (sidewalks, bike lanes, streets versus in-street
only). E-scooters are an emerging transportation modality being
introduced in cities nationwide, but are not regulated as motorcycles
by most transportation departments. Studies have identified e-scooter
injuries using keywords (“e-scooter”, “Lime”, “Bird”, “scoot”, “scoter”,
”skoot”, “scotter”, “schoot”, or ”sccot.” etc.) present in the medical
record and/or in syndromic surveillance data (e.g., chief complaint and
triage note). Head injuries are some of the most common e-scooter
injuries. Other common injuries include fractures and dislocated joints.
Adverse Incidents due to Therapeutic and

Rehabilitative Ophthalmic Devices
Two new codes were created to report ophthalmic related adverse

incidents. Code Y77.11, Contact lens associated with adverse
incidents, is specific for adverse incidents related to contact lenses.
Code Y77.19, Other therapeutic (nonsurgical) and rehabilitative
ophthalmic devices associated with adverse incidents, is for other
types of ophthalmic devices.
Contact lens wearers are at risk for contact lens-related eye

infections, especially if they are sleeping or napping in their lenses.
Sleeping in contact lenses increases the risk for corneal infection
regardless of lens material and frequency of overnight use. It is
important that contact lens wearers follow their eye care professional’s
recommendation for proper wear and care of contact lenses.
These codes were created at the request of the American Optometric

Association (AOA) to facilitate better data collection efforts related to
contact lens and other ophthalmic devices related adverse events.

Z Codes Update
New Z codes were created as noted below.
Observation
There are three new Z encounters for observation for suspected

conditions ruled out as follows:
• Ingested foreign body (Z03.821)

• Aspirated (inhaled) foreign body (Z03.822)
• Inserted (injected) foreign body (Z03.823)
The new codes will serve to identify, track, and justify resource
utilization for encounters for patients where the presence of a
foreign body may be suspected and clinical evaluation is required to
determine the presence of a foreign object.

ICD-10-PCS NEW/REVISED CODES
A summary of the Fiscal Year 2021 (FY 2021) ICD-10-PCS changes
effective October 1, 2020 is provided below. The addenda changes
demonstrating the specific revisions to the code titles are not included
in the explanations below. The FY 2021 ICD-10-PCS updates,
including the complete list of ICD-10-PCS code titles, addenda, and
a conversion table showing changes from the previous year are
available on the Centers for Medicare & Medicaid Services (CMS)
website at https://www.cms.gov/medicare/icd-10/2021-icd-10-pcs.
There are 544 new ICD-10-PCS codes effective October 1, 2020.

There were 0 revised code titles and 0 codes deleted.
The majority of new codes are in Section 0-Medical and Surgical.

There are also a small number of changes in Sections 1-Obstetrics,
3-Administration, 4-Measurement and Monitoring, 5-Extracorporeal
or Systemic Assistance and Performance, 8-Other Procedures,
B-Imaging, D-Radiation Therapy, and X-New Technology.
The specific changes are described below by section. Additions are

shown as underlined, and deletions are shown as strikeouts in the
excerpts from the ICD-10-PCS Tables below. The changes originate
from public comments, CMS internal review, as well as questions
submitted to Coding Clinic discussed by the Editorial Advisory Board
for Coding Clinic with recommendations for more specific values.
Section 0-Medical and Surgical
Insertion of Radioactive Element
In the Medical and Surgical section, the device value 1 Radioactive

Element has been added to the root operation Insertion tables
listed below. The change was made to support complete coding for
brachytherapy procedures where a radioactive element is left in the
body at the end of the procedure. This addition results in 151 new
ICD-10-PCS codes.

Table Root Operation/Body System
00H Insertion of Central Nervous System and Cranial
Nerves
01H Insertion of Peripheral Nervous System
07H Insertion of Lymphatic and Hemic Systems
09H Insertion of Ear, Nose, Sinus
0CH Insertion of Mouth and Throat
0DH Insertion of Gastrointestinal System
0FH Insertion of Hepatobiliary System and Pancreas
0GH Insertion of Endocrine System
0TH Insertion of Urinary System
0UH Insertion of Female Reproductive System
0VH Insertion of Male Reproductive System
Device
1 Radioactive element
Atrium Bypass Qualifier
In table 021, Heart and Great Vessels, Bypass, the qualifier value
Atrium, Right, has been added to apply to the body part value Atrium,
Left, and applied to the approach value Percutaneous. This change
enables capture of procedures such as unidirectional left to right atrial
shunt performed for treatment of congestive heart failure.
Body Part Approach Device Qualifier

7 Atrium, Left 3 Percutaneous J Synthetic 6 Atrium, Right
Substitute
Question:
A patient with a history of congestive heart
failure (CHF) with Class III-IV symptoms
underwent placement of a V-wave atrial septal
shunt device. Venous access was obtained
from the right femoral vein. An atrial septal
puncture was performed and a guidewire was
advanced into the superior vena cava. A trans-
septal puncture was made at the mid-portion

and slightly posterior aspect of the right atrium
into the left atrium. The V-wave shunt was
advanced (via trans-septal catheterization)
into the left atrium and positioned across the
septum. How is this procedure coded in ICD-
10-PCS?
Answer:
Assign the following procedure code:
02173J6 Bypass left atrium to right atrium

with synthetic substitute,
percutaneous approach.
This procedure meets the definition of the

root operation Bypass, “Altering the route of
passage of the contents of a tubular body
part.” The V-wave atrial septal shunt is a new
interventional cardiology procedure. The shunt
is described as “unidirectional left-to-right
interatrial shunting.” The device is placed within
the septum between the right and left atria and
acts as a valve, which opens when pressure
within the left atrium reaches an elevated level;
blood is then shunted over to the right atrium
reducing the level of left atrial pressure. This
device is being used to treat patients with
severe CHF as part of the Relieve HF trial to
reduce lung congestion symptoms in advanced
heart failure.
New Fragmentation Tables
A large number of changes have been made resulting in 116 new

codes to fully describe intravascular ultrasound assisted thrombolysis
procedures with tissue plasminogen activator (tPA) as well as
peripheral intravascular lithotripsy. Both procedures are classified to
the root operation Fragmentation: Breaking solid matter in a body part
into pieces. The change consists of adding new body part values to
existing table Heart and Great Vessels, Fragmentation (02F), creation
of four new tables with the root operation Fragmentation for the body
systems Upper Arteries (03F), Lower Arteries (04F), Upper Veins

(05F) and Lower Veins (06F), and creation of the Qualifier Ultrasonic,
for all of these tables. The changes are illustrated in more detail
below.
• In table 02F, Heart and Great Vessels, Fragmentation, body

part values have been added as noted below, along with the
qualifier value Ultrasonic.

P Pulmonary Trunk 3 Percutaneous Z No Device 0 Ultrasonic
Q Pulmonary Artery, Z No Qualifier
Right
R Pulmonary Artery,
Left
S Pulmonary Vein,
Right
T Pulmonary Vein,
Left
• New table 03F, Upper Arteries, Fragmentation, was created with

the following body part values below, along with the qualifier value
Ultrasonic.

2 Innominate Artery 3 Percutaneous Z No Device 0 Ultrasonic
3 Subclavian Artery, Z No Qualifier
Right
4 Subclavian Artery,
Left
5 Axillary Artery,
Right
6 Axillary Artery, Left
7 Brachial Artery,
Right
8 Brachial Artery,
Left
9 Ulnar Artery, Right
A Ulnar Artery, Left
B Radial Artery,
Right
C Radial Artery, Left
Y Upper Artery

• New table 04F, Lower Arteries, Fragmentation, was created
with the following body part values below, along with the
qualifier value Ultrasonic.

C Common Iliac 3 Percutaneous Z No Device 0 Ultrasonic
Artery, Right Z No Qualifier
D Common Iliac
Artery, Left
E Internal Iliac
Artery, Right
F Internal Iliac
Artery, Left
H External Iliac
Artery, Right
J External Iliac
Artery, Left
K Femoral Artery,
Right
L Femoral Artery,
Left
M Popliteal Artery,
Right
N Popliteal Artery,
Left
P Anterior Tibial
Artery, Right
Q Anterior Tibial
Artery, Left
R Posterior Tibial
Artery, Right
S Posterior Tibial
Artery, Left
T Peroneal Artery,
Right
U Peroneal Artery,
Left
Y Lower Artery

• New table 05F, Upper Veins, Fragmentation, was created with
Ultrasonic.

3 Innominate Vein, 3 Percutaneous Z No Device 0 Ultrasonic
Right Z No Qualifier
4 Innominate Vein,
Left
5 Subclavian Vein,
Right
6 Subclavian Vein,
Left
7 Axillary Vein,
Right
8 Axillary Vein, Left
9 Brachial Vein,
Right
A Brachial Vein,
Left
B Basilic Vein,
Right
C Basilic Vein, Left
D Cephalic Vein,
Right
F Cephalic Vein,
Left
Y Upper Vein

• New table 06F, Lower Veins, Fragmentation, was created with
Ultrasonic.

C Common Iliac 3 Percutaneous Z No Device 0 Ultrasonic
Vein, Right Z No Qualifier
D Common Iliac
Vein, Left
F External Iliac
Vein, Right
G External Iliac
Vein, Left
H Hypogastric
Vein, Right
J Hypogastric
Vein, Left
M Femoral Vein,
Right
N Femoral Vein,
Left
P Saphenous
Vein, Right
Q Saphenous
Vein, Left
Y Lower Vein
Intravascular Ultrasound Assisted Thrombolysis
Conventional catheter-directed thrombolysis generally uses a multi-

side hole catheter placed adjacent to the thrombus. Thrombolytics
are then delivered directly to the thrombus via the catheter. Newer
technology utilizes pulses of ultrasonic energy to temporarily make
the fibrin in the thrombus more porous and increase fluid flow within
the thrombus. High frequency, low-intensity ultrasonic waves create
a pressure gradient that drives the thrombolytic into the thrombus
and keeps it in close proximity to the binding sites. An example of this
technology is the EkoSonic® Endovascular System (EKOS™ system).
The most common indication for ultrasound assisted thrombolysis is
the treatment of pulmonary embolism. However, this therapy is also
indicated to treat deep venous thrombosis and peripheral arterial
occlusion.

Please note that facilities may choose to report the administration of
the thrombolytic agent separately using the appropriate codes noted below:
3E06317 Introduction of other thrombolytic into central

artery, percutaneous approach, or
3E05317 Introduction of other thrombolytic into peripheral

artery, percutaneous approach, or
3E04317 Introduction of other thrombolytic into central vein,

percutaneous approach, or
3E03317 Introduction of other thrombolytic into peripheral

vein, percutaneous approach.
Intravascular Lithotripsy
Intravascular lithotripsy is used alone or with stent placement to treat

plaque in the arteries. Shockwave lithotripsy is a new technology that
uses a traditional balloon catheter with multiple mounted emitters
to provide pulsatile sonic energy to fragment calcified calcifications
within the vessels. The procedure is performed by delivering an
intravascular lithotripsy (IVL) catheter across a calcified lesion
over a wire and the integrated balloon is expanded. An electrical
discharge from the emitters vaporizes the fluid within the balloon,
creating a rapidly expanding and collapsing bubble that generates
sonic pressure waves. The waves travel through soft vascular tissue,
selectively cracking vessel wall intimal and medial calcium.
Question:
The patient presented with stenosis of the right
external iliac and common femoral arteries
and underwent a percutaneous transluminal
angioplasty (PTA) with shockwave lithotripsy
therapy. During the procedure, a shockwave
lithotripsy balloon was inserted and two
treatments of shockwaves were delivered. A
drug-coated balloon was then inserted and left
in place for three minutes. Final angiography
revealed excellent results and reduction in
stenosis. How is shockwave lithotripsy therapy
and drug-coated balloon angioplasty of the
external iliac and common femoral arteries coded?

Answer:
Assign the following ICD-10-PCS codes for the
angioplasty with shockwave lithotripsy therapy
of the right external iliac and common femoral
arteries:
047H3Z1 Dilation of right external iliac

artery using drug-coated
balloon, percutaneous approach
047K3Z1 Dilation of right femoral artery

using drug-coated balloon,
percutaneous approach
04FH3ZZ Fragmentation of right external

iliac artery, percutaneous
approach
04FK3ZZ Fragmentation of right femoral

artery, percutaneous approach.
Question:
A patient was admitted for transfemoral aortic
valve replacement (TAVR); however, due to
horseshoe calcification at the right common
iliac ostium, an intravascular lithotripsy was
performed prior to the TAVR to treat the
patient’s peripheral arterial disease and to
allow for sheath placement necessary for
the TAVR procedure. During the lithotripsy, a
balloon was advanced across the lesion and
inflated to a maximum of four atmospheres
and 120 pulses were delivered. The balloon
was then withdrawn to the origin of the external
iliac and 60 additional pulses were delivered.
Follow-up angiography revealed an excellent
angiographic result without dissection. How
is shockwave lithotripsy therapy of the right
common and external iliac arteries coded?

Answer:
Assign the following ICD-10-PCS codes for the
intravascular shockwave lithotripsy of the right
common and external iliac arteries:
04FC3ZZ Fragmentation of right common

approach
04FH3ZZ Fragmentation of right external

approach.
The objective of the procedure is to break up

the arterial calcifications. While the procedure
involves a balloon, the purpose of the balloon is
to facilitate the energy (pulse) transfer. Dilation
codes are not assigned since there was no
mention of “dilating the vessel” (or specifically
performing a percutaneous transluminal
angioplasty). Assign separate codes for the
TAVR.
Transapical Mitral Valve Repair with Device
In table 02U, Heart and Great Vessel, Supplement, the qualifier

value H Transapical has been added for the body part value Mitral
Valve, the percutaneous approach, and device value J Synthetic
Substitute. The procedure is performed on a beating heart, under
trans-esophageal echocardiography via a transapical approach,
with placement of a permanent synthetic device that reinforces the
chordae tendineae and prolapsed posterior leaflet to correct for mitral
regurgitation. This change will identify mitral valve repairs involving
placement of a device to augment or reinforce valve function, using
a transapical approach. For example, assign code 02UG3JH,
Supplement mitral valve with synthetic substitute, transapical,
percutaneous approach, for transcatheter repair via a transapical
delivery system.

G Mitral Valve 3 Percutaneous J Synthetic H Transapical
Substitute

Bone Marrow Body Part
In table 07H, Lymphatic and Hemic Systems, Insertion, the body part
value for Bone Marrow has been added. In addition, as noted earlier,
the device value Radioactive element has been added to support
coding for brachytherapy procedures where a radioactive element
is left in the body at the end of the procedure. This change allows
the capture of procedures for the insertion of radioactive elements,
infusion devices and other devices into the bone marrow.

T Bone Marrow 0 Open 1 Radioactive Z No Qualifier
3 Percutaneous element
4 Percutaneous 3 Infusion
Endoscopic Device
Y Other Device
Bypass Pancreatic Duct to Stomach
In table 0F1, Hepatobiliary System and Pancreas, Bypass, the

qualifier value Stomach has been added for the Pancreatic Duct body
part value. This change enables the identification of procedures such
as pancreaticogastrostomy performed for the decompression of the
pancreatic ductal system.

D Pancreatic 0 Open D Intraluminal 4 Stomach
Duct 4 Percutaneous device
Endoscopic Z No Device
Question:
A patient, who is status post
pancreaticoduodenectomy, presents with
stenosis of the pancreaticojunostomy. A robotic
lateral pancreaticogastrostomy is performed
with the objective of decompressing the
pancreatic ductal system. At surgery, robotic
scissors were used to open up the pancreatic
duct along its length extending out towards
the tail. The back wall of the stomach was

opened up and the pancreatic duct was
anastomosed to the stomach. How is a lateral
pancreaticogastrostomy coded in ICD-10-PCS?
Answer:
Assign the following procedure codes:
0F1D4Z4 Bypass pancreatic duct to

stomach, percutaneous
endoscopic approach; and
8E0W4CZ Robotic assisted procedure

of trunk region, percutaneous
endoscopic approach.
Insertion of Other Device into Subcutaneous Tissue and Fascia
The device value “Y” Other Device, has been added to table 0JH,
Subcutaneous Tissue and Fascia, Insertion, for the Subcutaneous
Tissue and Fascia, chest, back and abdomen respectively as noted
below. Please note that the device value Other Device already exists
for the subcutaneous tissue and fascia for the head and neck, upper
and lower extremities, and trunk.

6 Subcutaneous 0 Open Y Other Device Z No
Tissue and 3 Percutaneous Qualifier
Fascia, Chest
7 Subcutaneous
Tissue and
Fascia, Back
8 Subcutaneous
Tissue and
Fascia, Abdomen

Insertion of Subcutaneous Pump System for Ascites Drainage
In table 0W1, Anatomical Regions, Bypass, the qualifier value 6

Bladder, has been added for the bypass from peritoneal cavity to
the bladder. This change will identify the procedures in which a fully
internal route of passage for the fluid from the peritoneal cavity to the
bladder is created.

G Peritoneal 0 Open J Synthetic 6 Bladder
Cavity 3 Percutaneous Substitute
4 Percutaneous
Endoscopic
The buildup of ascitic fluid in the peritoneal cavity is a common

complication for patients with cirrhosis. The alfapump® system is an
alternative to serial paracentesis for patients with refractory ascites.
The system consists of an implanted subcutaneous device that allows
fluid to be moved from the peritoneal cavity to the urinary bladder
where it is then eliminated via urination. The alfapump® system is
wirelessly charged using a hand-held Smart Charger, which can also
be used to wirelessly adjust the settings. One catheter is implanted in
the peritoneal cavity to collect fluid and the other catheter is implanted
in the urinary bladder to receive fluid. The alfapump® is placed in a
subcutaneous pocket made by a single incision on the abdominal right
or left upper quadrant. Two small additional incisions are made for the
percutaneous insertion of the peritoneal and bladder catheters which
are then tunneled to the pump pocket and attached to the alfapump®
system prior to closure of the implantation pocket.
For the percutaneous implantation of the alfapump® for ascites

drainage, assign the following ICD-10-PCS codes:
0W1G3J6 Bypass peritoneal cavity to bladder with synthetic

substitute, percutaneous approach, for the procedure
to alter the route of passage of the ascitic fluid from the
peritoneal cavity to the bladder.
0JH80YZ Insertion of other device into abdomen subcutaneous

tissue and fascia, open approach, for the insertion of
the pump in the abdominal subcutaneous pocket.

Transvaginal Drainage of Pelvis
In table 0W9, Anatomical Regions, Drainage, for the body part value
Pelvic Cavity, the following approach values were added: 7 Via
Natural or Artificial Opening and 8 Via Natural or Artificial Opening
Endoscopic.
This change enables the identification of pelvic drainage performed

using a transvaginal approach.
Body Part Approach

J Pelvic Cavity 7 Via Natural or Artificial Opening
8 Via Natural or Artificial Opening Endoscopic
Removal of External Fixation Device
In table 0QP, Lower Bones, Removal, the device value 5 External

Fixation Device, has been added to the body parts Lumbar Vertebra,
Sacrum, Acetabulum Right, Acetabulum Left, and Coccyx to identify
when an external fixation device is removed from these body parts.
Body Part Approach Device

0 Lumbar Vertebra 0 Open 5 External Fixation
1 Sacrum 3 Percutaneous Device
4 Acetabulum, Right 4 Percutaneous
5 Acetabulum, Left Endoscopic
S Coccyx X External
Intramedullary Sustained Compression Joint Fusion
A new device value, Internal Fixation Device, Sustained Compression,

has been added to tables 0RG, Upper Joints, Fusion, and 0SG, Lower
Joints, Fusion, to describe fusion of the upper and lower joints using
an intramedullary sustained compression internal fixation device.
At table 0RG, Upper Joints, Fusion, the change applies to the body
parts listed below:

L Elbow Joint, Right 0 Open 3 Internal Fixation
M Elbow Joint, Left 3 Percutaneous Device, Sustained
N Wrist Joint, Right 4 Percutaneous Compression
P Wrist Joint, Left Endoscopic
Q Carpal Joint, Right
R Carpal Joint, Left
S Carpometacarpal Joint,
Right
T Carpometacarpal Joint, Left
U Metacarpophalangeal
Joint, Right
V Metacarpophalangeal
Joint, Left
W Finger Phalangeal Joint,
Right
X Finger Phalangeal Joint,
Left
At table 0SG, Lower Joints, Fusion, the change applies to the body
parts listed below:

9 Hip Joint, Right 0 Open 3 Internal Fixation
B Hip Joint, Left 3 Percutaneous Device, Sustained
C Knee Joint, Right 4 Percutaneous Compression
D Knee Joint, Left Endoscopic
F Ankle Joint, Right
G Ankle Joint, Left
H Tarsal Joint, Right
J Tarsal Joint, Left
K Tarsometatarsal Joint, Right
L Tarsometatarsal Joint, Left
M Metatarsal-Phalangeal
Joint, Right
N Metatarsal-Phalangeal
Joint, Left
P Toe Phalangeal Joint, Right
Q Toe Phalangeal Joint, Left

Current conventional internal fixation devices used in upper and lower
joint fusion procedures include screws, plates, and intramedullary
nails. These devices hold bone ends together while they fuse, with the
surgeon generally manually compressing the bones together before
using the fixation devices to “lock” the bones in place. Such devices
offer “passive compression,” meaning that they do not incorporate
any mechanism to continue to exert compression if any biological
or mechanical changes occur at the fusion site. Examples of such
changes include bone resorption at the bone ends, implant shifting
and loosening, or joint settling. The changes can prevent the ends of
the bones from having adequate contact, resulting in fibrous tissue
formation rather than bone, and preventing fusion from occurring as
gaps form between bones.
Newer technology for applying sustained compression uses Nitinol, an

alloy of nickel and titanium. Nitinol devices can exert a sustained force
if they are stretched and prevented from returning to their original
shape. Recently, intramedullary nails incorporating an internal Nitinol
component were made available clinically for use in the foot and
ankle. This new technology is able to sustain compression across the
joint during the healing process.
Male Reproductive Organ Transplant
The root operation “Transplantation” has been added to the body

system Male Reproductive System, for the body parts scrotum and
penis. This will allow the capture of transplants of these organs. This
change results in a new table 0VY as noted below.
Section: 0 Medical and Surgical

Body System: V Male Reproductive System
Operation: Y Transplantation
5 Scrotum 0 Open Z No Device 0 Allogeneic
S Penis 1 Syngeneic
2 Zooplastic
Question:
A patient with an acquired loss of his penis
and scrotum due to a war injury, presented for
penile and scrotal transplantation. Previous
penile and abdominal skin grafts were removed.

The allogeneic donor penile and scrotal graft
including vascular pedicles were harvested. A
catheter was placed through the donor penis,
the recipient stump and continued into the
recipient’s bladder. Using sutures, the donor
and recipient’s urethral mucosa and corpora
spongiosum tissue were approximated. Next,
both corpora cavernosa tissues were aligned
and fixed with sutures. Following fixation of
the penis, microvascular anastomoses of the
vascular pedicles and dorsal penile nerves
from donor to recipient were performed. Moving
to the perineum, the donor scrotal skin was
sutured into the subdermis and skin. What
codes are assigned for this penile and scrotal
transplantation procedure?
Answer:
Assign the following ICD-10-PCS codes:
0VYS0Z0 Transplantation of penis,

allogeneic,open approach; and
0VY50Z0 Transplantation of scrotum,

allogeneic,open approach.
Section 1-Obstetrics
Extraction of Ectopic Products of Conception
In the Obstetrics section in table 10D, Extraction of Products of

Conception, approach values for Open and Percutaneous Endoscopic
have been added for body part value 2 Products of Conception,
Ectopic. This change allows the identification of open or laparoscopic
procedures for the removal of ectopic pregnancy.

2 Products of 0 Open Z No Device Z No Device
Conception, 4 Percutaneous
Ectopic Endoscopic

Question:
A patient was admitted with vaginal bleeding
and lower abdominal pain. Twin gestation
in the left fallopian tube was revealed
during diagnostic laparoscopy, along with a
bleeding rent in the distal aspect of the tube.
A laparotomy was performed and extended in
both transverse directions. The left tube was
exteriorized, gentle pressure was applied on
the left tube, and the products of conception
were expelled from the rent in the left tube. The
rent was then repaired with sutures. What is
the appropriate root operation and approach
value for laparotomy with removal of ectopic
pregnancy through a rent in the left tube, by
applying gentle pressure?
Answer:
Assign the following procedure codes:
10D27ZZ Extraction of products of

conception, ectopic, open
approach, for removal of
products of conception from the
left tube by applying pressure to
the tube; and
0UQ60ZZ Repair left fallopian tube, open

approach, for the repair of the
rent in the fallopian tube.
Section 3-Administration
Transfusion Stem Cell Progenitor Cells
In the Administration section, at table 302, Circulatory body

system, Transfusion, a new substance value has been added for
Hematopoietic Stem/Progenitor Cells, Genetically Modified.

Body System Approach Function/Device Qualifier
3 Peripheral 0 Open C Hematopoietic 0 Autologous
Vein 3 Percutaneous Stem/Progenitor
4 Central Vein Cells, Genetically
Modified
The new codes will allow the reporting of the administration of

genetically modified hematopoietic stem cell treatments, including
based gene therapies such as OTL-101. OTL-101, the first ex vivo
autologous CD34+ hematopoietic stem cell progenitor cells (HSPC)
based gene therapy (HSPC-GT) available for use in the US, is
intended for the treatment of patients diagnosed with adenosine
deaminase severe combined immunodeficiency (ADA-SCID).
ADA-SCID is a rare autosomal recessive, monogenic, inherited

immune disorder. The main characteristics of the condition are
profound lymphopenia; impaired differentiation and function of T
cells, B cells, and natural killer cells; recurrent infections; and failure
to thrive. Patients suffering from ADA-SCID are also affected by non-
immunological abnormalities, such as hepatic dysfunction, pulmonary
insufficiency, renal disease, skeletal alterations, neurological deficits
affecting motor function and hearing, and cognitive/behavioral
deficits. In the US, the condition is usually diagnosed during newborn
screening and many patients rarely survive beyond 1 to 2 years of
age unless immune function is restored.
Autologous CD34+ HSPCs are harvested from the patient’s bone

marrow and then genetically modified ex vivo (outside of the body).
The modified cells are then cryopreserved and OTL-101 is transported
to the treatment site in a dry nitrogen shipping container. The
genetically modified cells are reinfused into patients following a non-
myeloablative conditioning regimen, which reduces defective cells and
favors the engraftment of genetically modified cells expressing ADA.
OTL-101 is infused intravenously over 5 to 15 minutes without use of
a leukocyte depleting filter.

Section 4-Measurement and Monitoring
Measurement of Intracranial Arterial Flow
In table 4A0, Physiological Systems, Measurement, existing qualifier

D Intracranial, has been applied to the Body System Arterial, the
external approach, and the function value Flow. This change will
identify the use of non-invasive techniques for measuring cerebral
artery flow/occlusion, such as software that analyzes computed
tomography angiogram (CTA) of the head and neck for large vessel
occlusion (LVO).
Body System Approach Function/Device Qualifier

3 Arterial X External 5 Flow D Intracranial
For example, ContaCT is a radiological computer-assisted triage and

notification software system that analyzes CTA brain images and
sends notifications to a neurovascular specialist(s) when a suspected
LVO has been identified. It is anticipated that early notification can
reduce time to treatment and increase access to treatments, like
mechanical thrombectomy, in patients with acute ischemic stroke.
Please note that the CTA is reported separately using the appropriate
code in section B, Imaging.
Percutaneous Endoscopic Measurement

of Portal Venous Pressure
In the Measurement and Monitoring section, approach value 4

Percutaneous Endoscopic, has been applied to body system 4
Venous, function value B Pressure, and qualifier value 2 Portal, in
table 4A0. This will allow the capture of measurements of venous
portal pressure using a percutaneous endoscopic approach.
Body System Approach Function/ Qualifier

Device
4 Venous 4 Percutaneous B Pressure 2 Portal
Endoscopic

Intercompartmental Pressure Measurement
In table 4A0, Physiological Systems, Measurement, a new qualifier

E Compartment, has been created for the Musculoskeletal
body system, percutaneous approach, and the function value B
Pressure. This change will allow the identification of percutaneous
intercompartmental pressure measurement.
Body System Approach Function/ Qualifier

Device
F Musculoskeletal 3 Percutaneous B Pressure E Compartment
Question:
A patient experienced infiltration of the IV in
her left wrist that caused significant swelling
of her forearm and hand. At bedside, an
intercompartmental pressure reading was
performed to rule out acute compartment
syndrome. The sites were checked using a
needle and a compartment measurement
device. What is the code assignment for
measuring the intercompartmental pressure of
the forearm and hand?
Answer:
Assign the following ICD-10-PCS code:
4A0F3BE Measurement of musculoskeletal
pressure, compartment,
Question:
A patient was seen for possible compartment
syndrome following an injury to the left tibia.
Interstitial fluid pressures were taken of the four
compartments of the leg using a wick catheter.
The wick catheter was inserted into the deep

posterior compartment via a 16-gauge catheter
with a local anesthetic under sterile technique.
It was taped to the skin. The syringe was
released and the compartment pressure was
taken. The same procedure was performed

on the anterior compartment after one hour,
the superficial posterior compartment after
two hours and the lateral compartment after
4 hours. What is the code assignment for
measuring the compartment pressure of the left
leg?
Answer:
In this case, a catheter was inserted and was
left in place with documented multiple readings
at different points in time. Assign the following
ICD-10-PCS codes:
0KHY3YZ Insertion of other device into

lower muscle, percutaneous
approach, and
4A0F3BE Measurement of musculoskeletal

pressure, compartment,
Insertion is the appropriate root operation, since

the catheter is left in place to allow for multiple
intercompartmental pressure measurements
taken at different periods.
Section 5-Extracorporeal or Systemic Assistance

and Performance
Ventilatory Assistance by High Flow or High Velocity

Nasal Cannula Devices
In table 5A0, Physiological Systems, Assistance, new qualifier value

A High Nasal Flow/Velocity, has been added and applied to the
body system value 9 Respiratory, and function value 5 Ventilation, to
identify ventilatory assistance provided by high flow or high velocity
nasal cannula devices. The change allows the reporting of this service
for three duration values as shown below.
Nasal high flow therapy is a type of respiratory support method that

delivers a high flow (liters per minute) of oxygen often in conjunction
with compressed air and humidification through a nasal cannula. It is
considered a less invasive alternative to ventilator care.

Body System Duration Function Qualifier
9 Respiratory 3 Less than 24 5 Ventilation A High Nasal
Consecutive Hours Flow/Velocity
4 24-96
Consecutive Hours
5 Greater than 96
Consecutive Hours
Section 8-Other Procedures
Near Infrared Spectroscopy for Tissue Viability Assessment
In section 8, Other Procedures, a new method value Near Infrared

Spectroscopy for the body region, Circulatory System, has been
created in table 8E0 to describe the utilization of Near Infrared
Spectroscopy (NIRS) tissue oxygenation imaging. NIRS is used to
measure or monitor tissue oxygen saturation levels when assessing
tissue viability during surgical procedures or during the postoperative
management period using a non-invasive external approach.
Body Region Method

2 Circulatory System D Near Infrared Spectroscopy
NIRS technology assesses tissue viability by measuring approximate

values of tissue oxygen saturation. The measurements provided can
assist with decisions to determine tissue survival. This information
can be valuable during repair and closure procedures in treatment of
traumatic injuries, and to assess limb preservation and tissue survival
in a wide range of wounds, tissue loss, tissue repair and grafting
procedures, and in ongoing post-operative monitoring.
Two examples of this technology are the SnapshotNIR handheld

device and the Intra Ox Handheld Tissue Oximeter. The SnapshotNIR
device is positioned at a pre-set distance from the surface of the
skin to illuminate an area of tissue with a sequence of near infrared
wavelengths and then measures the back reflected light at each
wavelength. There is no need for attaching probes or puncturing a
vessel. The reflectance sequence is processed to provide an estimate
of the relative concentrations of oxyhemoglobin and deoxyhemoglobin
where the ratio is used to determine oxygen saturation levels (StO2)
in the tissue. Quantitative StO2 values across the tissue area are

imaged for analysis and stored for comparison to prior and future
measurements. SnapshotNIR provides a color image with the ability
for the user to observe quantitative StO2 values across the tissue
area, by selecting areas of interest in the image.
The Intra Ox Handheld Tissue Oximeter has a disposable sensor that

provides a measure of StO2. This device places the light delivery and
collection optics (contained within the sensor) directly on the skin. The
Intra Ox system provides a numerical StO2 value for a small amount
of tissue beneath.
Section B – Imaging
“Other Imaging” Type
In section B Imaging, a new third-character imaging type “Other

Imaging” has been created to classify imaging modalities “not
elsewhere classified”. This change allows the capture of new imaging
procedures without creating additional third character imaging types;
instead, qualifiers in the table are used to specify the new imaging
modality. The new value 5 Other Imaging was added to body systems
Hepatobiliary System and Pancreas and Anatomical Regions. These
changes are discussed in more detail below.
Fluorescence Imaging of Hepatobiliary System
In the Imaging Section, imaging type “Other Imaging” has been added
to the body system Hepatobiliary System and Pancreas, to allow the
capture of fluorescence imaging using Indocyanine Green Dye. This
change results in a new table BF5 as noted below.

Section: B Imaging
Body System: F Hepatobiliary System and Pancreas
Type: 5 Other Imaging
Body Part Contrast Qualifier Qualifier
0 Bile Ducts 2 Fluorescing 0 Indocyanine 0 Intraoperative
2 Gallbladder Agent Green Dye Z None
3 Gallbladder and Z None
Bile Ducts
5 Liver
6 Liver and Spleen
7 Pancreas
C Hepatobiliary
System, All
Indocyanine green (ICG) dye can be used intraoperatively during

laparoscopic cholecystectomy procedures to better visualize the
biliary tree anatomy and avoid bile duct injuries, which are the
most serious post-operative complications following laparoscopic
cholecystectomy. Please note that separate ICD-10-PCS codes
are assigned for the intraoperative near-infrared fluorescence
imaging of the hepatobiliary system using the ICG dye as well as the
cholecystectomy procedure.
Question:
The patient presents for robotic
cholecystectomy with Firefly™ indocyanine
green (ICG) cholangiogram. Firefly™ ICG
imaging uses infrared technology. How would
the intraoperative cholangiogram using infrared
imaging with ICG dye be coded?
Answer:
Assign the following ICD-10-PCS code:
BF50200 Other imaging of bile ducts

using fluorescing agent,
indocyanine green dye,
intraoperative, for the
intraoperative cholangiogram
using ICG dye.

Intraoperative fluorescent cholangiography
during robotic cholecystectomy is a new
technology that utilizes indocyanine green
imaging to provide real-time visualization of
the biliary anatomy. During cholecystectomy,
the laser light source illuminates the operative
site with infrared light, which causes the ICG
to fluoresce. The camera system detects the
fluorescing ICG as it passes through the biliary
circulation. ICG is administered via peripheral
IV.
Bacterial Autofluorescence Detection
In the Imaging Section, imaging type “Other Imaging” has been

added to the body system Anatomical Regions, to identify the use
of portable real-time imaging of an acute or chronic wound and
surrounding tissue for the presence, location, and load of bacteria
using autofluorescence detection. This change results in new table
BW5 as noted below.
Section: B Imaging
Body System: W Anatomical Regions
Type: 5 Other Imaging
Body Part Contrast Qualifier Qualifier
2 Trunk Z None 1 Bacterial Z None
9 Head and Neck Autofluorescence
C Lower Extremity
J Upper Extremity
The MolecuLight i:X® is a point-of-care handheld imaging device

for detection of bacteria to aid in the diagnosis and treatment of
skin wounds. The device allows the viewing and digital recording
of fluorescence emitted from a wound when exposed to an
excitation light. The device enables real-time standard light and
fluorescence imaging of bacteria and tissue components in wounds
and surrounding healthy skin of patients. The device visualizes the
presence of bacteria commonly found within or around wounds
through endogenous autofluorescence using no contrast agents.
This includes gram positive and gram-negative species, aerobes
and anaerobes (e.g., Staphylococcus, E. coli, Klebsiella, Proteus,
Enterobacter, Acinetobacter, Aeromonas, Bacteroides, and others).

Section D- Radiation Therapy
Cesium 131 Brachytherapy
In the Radiation Therapy section, a new isotope value 6 Cesium 131

(Cs-131), has been added to all Brachytherapy tables for the fifth
character modality qualifier value B Low Dose Rate resulting in 64
new ICD-10-PCS codes.
Modality Qualifier Isotope

B Low Dose Rate (LDR) 6 Cesium 131 (Cs-131)
The new isotope value 6 Cesium 131 (Cs-131), has been added to
the following tables in the Radiation Therapy System:
Table Body System

D01 Central and Peripheral Nervous System
D71 Lymphatic and Hematologic System
D81 Eye
D91 Ear, Nose, Mouth and Throat
DB1 Respiratory System
DD1 Gastrointestinal System
DF1 Hepatobiliary System and Pancreas
DG1 Endocrine
DM1 Breast
DT1 Urinary System
DU1 Female Reproductive System
DV1 Male Reproductive System
DW1 Anatomical Regions
Low dose rate (LDR) cesium 131 brachytherapy implants (often

referred to as brachytherapy “seeds”) are one of the most common
isotopes used to deliver low dose rate brachytherapy. The implants
are the size of a grain of rice and they release a personalized
radiation dose over a period of days to treat malignancies. The
cesium 131 seeds are usually implanted using minimally invasive
techniques through the introduction of brachytherapy needles inserted
under image guidance. These procedures are typically performed in
an operating room under general anesthesia. Alternatively, traditional
cesium 131 seeds may be implanted intraoperatively.

Cesium 131 seeds are used to treat solid mass tumors located
throughout the body with the most frequent sites being the brain, head
and neck, gynecologic sites, prostate, and lungs.
Intraoperative Radiation Therapy
In the Radiation Therapy Section, at code table D0Y, Other Radiation

of Central and Peripheral Nervous System, the modality qualifier C
Intraoperative Radiation Therapy, has been added as noted below.
The change will enable the capture of intraoperatively administered
radiation for targeted therapy of intracranial tumors or tumor beds.
There are already a number of codes for intraoperative radiation
therapy (IORT) in other body parts, but there were none for the
Central and Peripheral Nervous System.
Treatment Site Modality Qualifier Isotope Qualifier

0 Brain C Intraoperative Z None Z None
1 Brain Stem Radiation Therapy
6 Spinal Cord (IORT)
7 Peripheral Nerve
IORT is an intensive radiation treatment that is administered

intraoperatively allowing direct radiation to the target area while
sparing normal surrounding tissue. This type of radiation is used to
treat tumors that are difficult to remove surgically and when there is a
concern that microscopic amounts of cancer may remain.
Section X-New Technology
Cerebral Embolic Filtration Extracorporeal Flow Reversal Circuit
A new code has been created at table X2A, Cardiovascular

System, Assistance, to describe the use of reverse flow embolic
neuroprotection during transcarotid arterial revascularization (TCAR),
an intraoperative filtration procedure that utilizes an extracorporeal
flow reversal circuit.
Body Part Device/Substance/Technology

H Common Carotid Artery, Right 3 Cerebral Embolic Filtration,
J Common Carotid Artery, Left Extracorporeal Flow Reversal
Circuit

The TCAR procedure is performed to reduce the risk of stroke with
placement of a carotid artery stent. Traditional carotid artery stenting
is performed using instrumentation via the femoral artery being
advanced under fluoroscopy to the site of plaque obstructing the
carotid artery. In TCAR, access is obtained with a cut-down in the
neck to access the common carotid artery below the plaque, thereby
precluding the need to navigate instrumentation throughout the
peripheral and central vasculature and reducing fluoroscopy exposure
time.
Unlike other cerebral embolic filtration procedures currently used with

carotid artery stenting and transcatheter aortic valve replacement
(TVAR), the filter is not placed within the vasculature. The filter is
within the apparatus of the extracorporeal circuit and continually filters
out debris during the length of the procedure, returning the blood into
the femoral vein where it reenters the general circulation.
During the reverse flow embolic neuroprotection procedure performed

with TCAR, an extracorporeal circuit is created intraoperatively to
temporarily redirect and reverse blood flow away from the carotid
artery and into the femoral vein during placement of the stent. The
circuit works via a pressure gradient, in which blood naturally moves
from the high-pressure carotid artery to the low-pressure femoral vein.
Flow reversal keeps debris moving away from the brain, protecting
it from emboli. After the blood flow reversal is established, the same
transcarotid access site and sheath are used to deliver the predilation
balloon to the site of the plaque followed by delivery of the stent itself.
These interventions are performed above the site of the puncture
so there is no blood flow within the carotid artery at that time. After
confirmation of satisfactory placement of the stent, the sheath is
removed disconnecting the flow reversal neuroprotection circuit.
A separate code is assigned for the TCAR procedure with the

appropriate values from table 037, Dilation of Upper Arteries.

Implantation of Vertebral Mechanically Expandable Device
New table XNU, Bones, Supplement, provides two new codes to
describe the percutaneous implantation of mechanically expandable
(paired) synthetic substitute device to restore vertebral body height in
osteoporotic lumbar or thoracic vertebral compression fractures.

0 Lumbar Vertebra 5 Synthetic Substitute, Mechanically
4 Thoracic Vertebra Expandable (Paired)
One example of an implantable mechanically expandable synthetic
substitute is the SpineJack® system. The device is implanted
using a minimally invasive surgical technique via a percutaneous
transpedicular approach using fluoroscopic guidance. The implants
are inserted bilaterally into the vertebral body, then mechanically
expanded in a craniocaudal direction, restoring the vertebral height
and creating a cavity supported by the expanded implants. The area
surrounding the implants is then filled with polymethylmethacrylate
(PMMA) bone cement. As the bone cement hardens, it encapsulates
the implants helping to stabilize the restored vertebral body.
Introduction of New Therapeutic Substances

Twelve new substance values were added to code table XW0,
Anatomical Regions, Introduction, resulting in 23 new ICD-10-PCS
codes. The new substance values are listed below. Please note that
all of the substances below have a qualifier of 6, New Technology
Group 6, with the exception of Esketamine Hydrochloride, which has a
qualifier of 5, New Technology Group 5.
Device/Substance/Technology
0 Brexanolone
1 Eladocagene exuparvovec
2 Nerinitide
3 Durvalumab Antineoplastic
6 Lefamulin Anti-infective
8 Mineral-based Topical Hemostatic Agent
9 Ceftolozane/Tazobactam Anti-infective
A Cefiderocol Anti-infective
B Omadacycline Anti-infective
C Eculizumab
D Atezolizumab Antineoplastic
M Esketamine Hydrochloride

Brexanolone
Brexanalone (ZULRESSO™) is a neuroactive steroid gamma-

aminobutyric acid (GABA)A receptor positive modulator administered
via continuous intravenous (IV) infusion for the treatment of
postpartum depression (PPD) in adults. New ICD-10-PCS codes have
been created for the intravenous (IV) administration of Brexanolone
into the central or peripheral veins.
Eladocagene Exuparvovec
Eladocagene exuparvovec is a gene therapy consisting of an

adeno-associated virus (AAV) vector that delivers the human dopa
decarboxylase (DDC) gene to Aromatic L-amino acid decarboxylase
(AADC) deficient cells in the central nervous system. AADC deficiency
is a rare disease primarily of young children. These patients
commonly have profound motor dysfunction, hypotonia, hypokinesia,
oculogyric crisis (acute dystonia of the ocular muscles marked by
involuntary intermittent or sustained deviation of the eyes in a usually
upward direction), dystonia, autonomic dysfunction, extraneurologic
symptoms, and failure to gain weight. Current treatment options are
limited and yield few improvements for the majority of patients with
AADC deficiency.
Eladocagene exuparvovec is injected directly into the putamen (the

large dark lateral part of the basal ganglion within the brain) bilaterally
via established stereotactic surgical procedures using commercially
available guidance systems. The surgery is performed under general
anesthesia followed by a computed tomography (CT) scan and
magnetic resonance imaging (MRI) to check for acute bleeding and
any structural changes.
A single new ICD-10-PCS code has been created for the

administration of this gene therapy: XW0Q316, Introduction
of eladocagene exuparvovec into cranial cavity and brain,
percutaneous approach, new technology group 6.
A new ICD-10-CM code has been created to describe AADC

deficiency. Please refer to page15 of this issue of Coding Clinic for
additional information.

Nerinitide
Nerinitide (NA-1) is a novel peptide therapeutic administered as a

single intravenous dose to reduce ischemic damage after the onset
of acute stroke. It is also a member of a new class of neuroprotectant
drugs referred to as “PSD-95 Inhibitors.” NA-1 is administered
independently of other recanalization therapies.
New ICD-10-PCS codes have been created for the IV administration
of nerinitide into the central or peripheral veins.
Durvalumab Antineoplastic
Durvalumab (IMFINZI®) is a selective, high-affinity, human IgG1

monoclonal antibody (mAb), administered via intravenous IV infusion
for the treatment of extensive-stage small cell lung cancer.
New ICD-10-PCS codes have been created for the intravenous (IV)
administration of durvalumab into the central or peripheral veins.
Lefamulin Anti-infective
Lefamulin (XENLETA™) is an oral or intravenous (IV) antibacterial

used to treat adult patients with community-acquired bacterial
pneumonia (CABP) caused by the following susceptible
microorganisms: Streptococcus pneumoniae, Staphylococcus aureus
(methicillin-susceptible isolates), Haemophilus influenzae, Legionella
pneumophila, Mycoplasma pneumoniae, and Chlamydophila
pneumoniae.
New ICD-10-PCS codes have been created for the oral as well as the
IV administration of Lefamulin into the central or peripheral veins.
Mineral-based Topical Hemostatic Agent

Hemospray® Endoscopic Hemostat is mineral-based topical
hemostatic agent indicated for nonvariceal gastrointestinal bleeding.
The Hemospray® powder is delivered using an endoscope to access
the gastrointestinal tract. The delivery system is passed through
the accessory channel of the endoscope and positioned just above
the bleeding site. The Hemospray® powder, Bentonite, is propelled
through the application catheter, by release of carbon dioxide from
the cartridge located in the device handle and sprayed onto the
bleeding site. Hemospray® Endoscopic Hemostat acts by creating a
mechanical barrier over the site of the bleed.

Two new ICD-10-PCS codes have been created for the introduction
of mineral-based topical hemostatic agent into the upper or lower
gastrointestinal tract.
Ceftolozane/Tazobactam Anti-infective
Ceftolozane and tazobactam (ZERBAXA®) is a combination of

ceftolozane, a cephalosporin antibacterial, and tazobactam, a
β-lactamase inhibitor (BLI), used for the treatment of adult patients
with the following infections caused by designated susceptible
microorganisms:
• Complicated intra-abdominal infections (cIAI), used in

combination with metronidazole
• Complicated urinary tract infections (cUTI), including
pyelonephritis
• Hospital-acquired bacterial pneumonia and ventilator-
associated bacterial pneumonia (HABP/VABP)
New ICD-10-PCS codes have been created for the intravenous

(IV) administration of Ceftolozane/Tazobactam into the central or
peripheral veins.
Cefiderocol Anti-infective
Cefiderocol (FETROJA®) is a cephalosporin antibacterial drug

administered via intravenous infusion for the treatment of adult
patients with complicated urinary tract infections (cUTI), including
pyelonephritis caused by susceptible Gram-negative microorganisms,
who have limited or no alternative treatment options.
New ICD-10-PCS codes have been created for the IV administration

of cefiderocol into the central or peripheral veins.
Omadacycline Anti-infective
Omadacycline, also known by its trade name NUZYRA™, is a

tetracycline class antibacterial administered via IV to treat adult
patients with community-acquired bacterial pneumonia (CABP) or
acute bacterial skin and skin structure infections (ABSSSI) caused
by susceptible microorganisms. New ICD-10-PCS codes have been
created for the IV administration of omadacycline into the central or
peripheral veins.

Eculizumab
Eculizumab (Soliris®) is a complement inhibitor drug administered via

intravenous infusion to treat adults with neuromyelitis optica spectrum
disorder (NMOSD), a rare autoimmune disorder of the central nervous
system. The condition is characterized by neuroinflammatory relapses
that result in progressive and irreversible damage to the optic nerve
and spine. Relapses can cause blindness, paralysis and increased
overall mortality. New ICD-10-PCS codes have been created for the
IV administration of eculizumab into the central or peripheral veins.
Atezolizumab Antineoplastic
Atezolizumab (TECENTRIQ®) is an antineoplastic drug administered

via intravenous infusion for the treatment of adult patients with
extensive-stage small cell lung cancer. The drug is also FDA
approved for the treatment of locally advanced or metastatic urothelial
carcinoma, metastatic non-small cell lung cancer, and unresectable
locally advanced or metastatic triple-negative breast cancer. New
ICD-10-PCS codes have been created for the IV administration of
atezolizumab into the central or peripheral veins.
Esketamine Hydrochloride
Esketamine (SPRAVATOTM) is a nasal spray for treatment of

resistant depression. Please note that unlike the other ICD-
10-PCS codes effective October 1, 2020, under Table XW0,
Anatomical Regions, Introduction, esketamine hydrochloride has
a qualifier of 5, New Technology Group 5. A request to the ICD–10
Coordination and Maintenance Committee for approval for a unique
ICD–10–PCS procedure code to specifically identify esketamine
hydrochlorid was submitted for FY 2020 but not finalized as of the
time of the development of the FY 2020 IPPS/LTCH PPS final rule.
Subsequently, a new ICD-10-PCS code has been created for the
nasal administration of esketamine with qualifier of 5, New Technology
Group 5 used to coincide with the year of initial application
submission.

Transfusion of Chimeric Antigen Receptor (CAR)
T Cell Immunotherapy
New table XW2, Anatomical Regions, Transfusion, provides two

new codes to describe the intravenous administration of two
immunotherapy products as noted below.

3 Peripheral Vein 4 Brexucabtagene Autoleucel
4 Central Vein Immunotherapy
7 Lisocabtagene Maraleucel
Immunotherapy
Unlike other current chimeric antigen receptor (CAR) T-cell therapy

products which are classified in table XW0, Anatomical Regions,
Introduction, Brexucabtagene Autoleucel Immunotherapy and
Lisocabtagene Maraleucel Immunotherapy are classified under the
root operation Transfusion based on the root operation definitions and
receipt of public comments. CAR T-cell therapy is comprised of blood/
blood products; therefore, the root operation Transfusion is more
clinically accurate, because the full definition for the root operation
Introduction is “Putting in or on a therapeutic, diagnostic, nutritional,
physiological, or prophylactic substance except blood or blood
products.
A proposal was discussed at the September 2020 ICD-10

Coordination and Maintenance (C&M) Committee meeting to consider
modification of the current codes that are being reported for other
CAR T-cell products for consistency in the classification.
Brexucabtagene Autoleucel Immunotherapy
Brexucabtagene autoleucel (formerly known as KTE-X19) is an

autologous cellular chimeric antigen receptor (CAR) T-cell therapy that
modifies a patient’s cells to treat adults with relapsed/refractory (r/r)
mantle cell lymphoma (MCL). The patient’s own T-cells are harvested,
activated and genetically modified to produce a chimeric antigen
receptor (CAR). The modified T-cells are then expanded and infused
back into the patient. Brexucabtagene autoleucel is administered as a
single infusion patient-specific immunotherapy.

Lisocabtagene Maraleucel Immunotherapy
Lisocabtagene maraleucel (Liso-cel) is a CD19-directed, autologous

chimeric antigen receptor (CAR) T-cell immunotherapy that is
comprised of individually formulated CD8 (killer) and CD4 (helper)
CAR T-cells for the treatment of adult patients with relapsed or
refractory (r/r) large B-cell lymphoma. Lisocabtagene maraleucel
component CD4 and CD8 T-cells are purified and cultured separately
to maintain compositional control of each cell type. During culture,
each cell type is separately modified to have the CAR on the cell
surface, expanded and quantified, and frozen in two separate cell
suspensions (the CD4 and CD8 cell components). Lisocabtagene
maraleucel is administered via infusion at the same target dose of
CD4 and CD8 CAR T-cells.
Measurement of Infection
Two new codes have been created at table XXE, New Technology,
Physiological Systems, Measurement, with the Device/Substance/
Technology values noted below.
Device/Substance/Technology
N Infection, Positive Blood Culture Fluorescence Hybridization for
Organism Identification, Concentration and Susceptibility
Q Infection, Lower Respiratory Fluid Nucleic Acid-base Microbial

Detection
Positive Blood Culture Fluorescence Hybridization
Code XXE5XN6, Measurement of infection, positive blood culture

fluorescence hybridization for organism identification, concentration
and susceptibility, new technology group 6, was created to describe
the processing and analysis of a positive blood culture using the
Accelerate PhenoTest™ BC kit. The test is a fast, automated,
phenotypic, direct-from-positive blood culture identification and
antimicrobial susceptibility test that identifies 16 organisms. The
organisms are 6 Gram-positive bacteria, 8 Gram-negative bacteria
and 2 Candida species. The test also provides antibiotic susceptibility
of specific pathogens.

Microorganism identification is performed using fluorescence in
situ hybridization. Colocalization of target (green fluorescence) and
universal (red fluorescence) probe signals confirm the presence and
identity of the target organism while differentiating from non-specific
staining. Antimicrobial susceptibility testing (AST) is performed using
morphokinetic cellular analysis (MCA) which measures morphological
and kinetic changes over time of organisms exposed to antibiotics.
The technology provides results produced in approximately 2 hours
for the fast diagnosis of bloodstream infection as opposed to standard
of care methods that typically take 2-3 days.
Nucleic Acid-base Microbial Detection
Code XXEBXQ6, Measurement of infection, lower respiratory fluid

nucleic acid-base microbial detection, new technology group 6,
was created to identify the utilization of the BioFire® FilmArray®
Pneumonia Panel. The pneumonia panel is a new diagnostic
technology that simultaneously identifies 33 clinically relevant targets
from sputum (including endotracheal aspirate) and bronchoalveolar
lavage (including mini-BAL) samples in approximately an hour
compared to standard culture methods that often take days. The test
includes eight viral targets, eighteen bacterial targets, and seven
antimicrobial resistance gene targets. By providing semi-quantitative
results for bacterial targets commonly found colonizing the respiratory
tract, the test assists in distinguishing between normal colonization
and active infection from these organisms that cause pneumonia and
other lower respiratory tract infections.

CHANGES TO THE ICD-10-CM OFFICIAL
GUIDELINES FOR CODING AND REPORTING
A summary of the modifications to the ICD-10-CM Official Guidelines
for Coding and Reporting are included below. The complete guidelines
may be downloaded by visiting
http://www.cdc.gov/nchs/icd/icd10cm.htm
The modifications are published below using the following format:
Narrative changes appear in bold text (e.g., severe sepsis)

Items underlined were moved within the guidelines since October 1,
2020 (e.g., severe sepsis)
Deletions are shown as strikeouts (e.g., severe sepsis)
Italics are used to indicate revisions to heading changes
Section I. Conventions, general coding guidelines and chapter

specific guidelines
B. General Coding Guidelines . . .
14. Documentation by Clinicians Other than the

Patient’s Provider . . .
For social determinants of health, such as information
found in categories Z55-Z65, Persons with potential health
hazards related to socioeconomic and psychosocial
circumstances, code assignment may be based on medical
record documentation from clinicians involved in the care
of the patient who are not the patient’s provider since
this information represents social information, rather than
medical diagnoses. Patient self-reported documentation
may also be used to assign codes for social
determinants of health, as long as the patient self-
reported information is signed-off by and incorporated
into the health record by either a clinician or provider.

C. Chapter Specific Coding Guidelines . . .
Chapter 1: Certain Infectious and Parasitic Diseases
(A00-B99), U07.1 . . .
g. Coronavirus infections
COVID-19 infection (infection due to SARS-CoV-2)
Code only confirmed cases
Code only a confirmed diagnosis of the 2019

novel coronavirus disease (COVID-19) as
documented by the provider or documentation
of a positive COVID-19 test result. For a
confirmed diagnosis, assign code U07.1,
COVID-19. This is an exception to the hospital
inpatient guideline Section II, H. In this context,
“confirmation” does not require documentation
of a positive test result for COVID-19; the
provider’s documentation that the individual
has COVID-19 is sufficient.
If the provider documents “suspected,”

“possible,” “probable,” or “inconclusive”
COVID-19, do not assign code U07.1. Instead,
code the signs and symptoms reported. See
guideline I.C.1.g.1.g.
Sequencing of codes
When COVID-19 meets the definition of

principal diagnosis, code U07.1, COVID-19,
should be sequenced first, followed by
the appropriate codes for associated
manifestations, except when another guideline
requires that certain codes be sequenced
first, such as obstetrics, sepsis, or transplant
complications.
For a COVID-19 infection that progresses to

sepsis, see Section I.C.1.d. Sepsis, Severe
Sepsis, and Septic Shock

See Section I.C.15.s. for COVID-19 infection in
pregnancy, childbirth, and the puerperium
See Section I.C.16.h. for COVID-19 infection in

newborn
For a COVID-19 infection in a lung transplant

patient, see Section I.C.19.g.3.a. Transplant
complications other than kidney.
Acute respiratory manifestations of COVID-19

When the reason for the encounter/admission
is a respiratory manifestation of COVID-19,
assign code U07.1, COVID-19, as the principal/
first-listed diagnosis and assign code(s) for
the respiratory manifestation(s) as additional
diagnoses.
The following conditions are examples

of common respiratory manifestations of
COVID-19.
(i) Pneumonia
For a patient with pneumonia confirmed
as due to COVID-19, assign codes
U07.1, COVID-19, and J12.89, Other viral
pneumonia.
(ii) Acute bronchitis

For a patient with acute bronchitis
confirmed as due to COVID-19, assign
codes U07.1, and J20.8, Acute bronchitis
due to other specified organisms.
Bronchitis not otherwise specified (NOS)

due to COVID-19 should be coded using
code U07.1 and J40, Bronchitis, not
specified as acute or chronic.
(iii) Lower respiratory infection

If the COVID-19 is documented as being
associated with a lower respiratory
infection, not otherwise specified (NOS),

or an acute respiratory infection, NOS,
codes U07.1 and J22, Unspecified acute
lower respiratory infection, should be
assigned.
If the COVID-19 is documented as being

associated with a respiratory infection,
NOS, codes U07.1 and J98.8, Other
specified respiratory disorders, should
be assigned.
(iv) Acute respiratory distress syndrome

For acute respiratory distress syndrome
(ARDS) due to COVID-19, assign codes
U07.1, and J80, Acute respiratory
distress syndrome.
(v) Acute respiratory failure

For acute respiratory failure due to
COVID-19, assign code U07.1, and code
J96.0-, Acute respiratory failure.
(d) Non-respiratory manifestations of COVID-19
When the reason for the encounter/admission

is a non-respiratory manifestation (e.g., viral
enteritis) of COVID-19, assign code U07.1,
COVID-19, as the principal/first-listed diagnosis
and assign code(s) for the manifestation(s) as
additional diagnoses.

(e) Exposure to COVID-19
For asymptomatic individuals with actual or

suspected exposure to COVID-19, assign code
Z20.828, Contact with and (suspected) exposure
to other viral communicable diseases.
For symptomatic individuals with actual or

suspected exposure to COVID-19 and the
infection has been ruled out, or test results are
inconclusive or unknown, assign code Z20.828,
Contact with and (suspected) exposure to other

viral communicable diseases. See guideline
I.C.21.c.1, Contact/Exposure, for additional
guidance regarding the use of category Z20
codes.
If COVID-19 is confirmed, see guideline

I.C.1.g.1.a.
(f) Screening for COVID-19
During the COVID-19 pandemic, a screening

code is generally not appropriate. For
encounters for COVID-19 testing, including
preoperative testing, code as exposure to
COVID-19 (guideline I.C.1.g.1.e).
Coding guidance will be updated as new

information concerning any changes in the
pandemic status becomes available.
(g) Signs and symptoms without definitive

diagnosis of COVID-19
For patients presenting with any signs/

symptoms associated with COVID-19 (such
as fever, etc.) but a definitive diagnosis has
not been established, assign the appropriate
code(s) for each of the presenting signs and
symptoms such as:
• R05 Cough
• R06.02 Shortness of breath
• R50.9 Fever, unspecified
If a patient with signs/symptoms associated

with COVID-19 also has an actual or suspected
contact with or exposure to COVID-19, assign
Z20.828, Contact with and (suspected) exposure
to other viral communicable diseases, as an
additional code.

(h) Asymptomatic individuals who test positive for
COVID-19
For asymptomatic individuals who test

positive for COVID-19, see guideline I.C.1.g.1.a.
Although the individual is asymptomatic, the
individual has tested positive and is considered
to have the COVID-19 infection.
(i) Personal history of COVID-19

For patients with a history of COVID-19,
assign code Z86.19, Personal history of
other infectious and parasitic diseases.
(j) Follow-up visits after COVID-19 infection has

resolved
For individuals who previously had COVID-19

and are being seen for follow-up evaluation,
and COVID-19 test results are negative, assign
codes Z09, Encounter for follow-up examination
after completed treatment for conditions other
than malignant neoplasm, and Z86.19, Personal
history of other infectious and parasitic
diseases.
(k) Encounter for antibody testing
For an encounter for antibody testing that is not

being performed to confirm a current COVID-19
infection, nor is a follow-up test after resolution
of COVID-19, assign Z01.84, Encounter for
antibody response examination.
Follow the applicable guidelines above if the

individual is being tested to confirm a current
COVID-19 infection.
For follow-up testing after a COVID-19 infection,

see guideline I.C.1.g.1.j.

2. Chapter 2: Neoplasms (C00-D49)
General guidelines . . .
m. Current malignancy versus personal history of

malignancy . . .
Subcategories Codes from subcategories Z85.0 –
Z85.785 should only be assigned for the former site
of a primary malignancy, not the site of a secondary
malignancy. Codes from subcategory Code Z85.8-
,89 may be assigned for the former site(s) of either
a primary or secondary malignancy included in this
subcategory. . . .
4. Chapter 4: Endocrine, Nutritional, and Metabolic

Diseases (E00-E89)
a. Diabetes mellitus . . .
3) Diabetes mellitus and the use of insulin and, oral

hypoglycemics, and injectable non-insulin
drugs . . .
If the patient is treated with both oral medications
and insulin, only the code for long-term (current)
use of insulin should be assigned. If the patient
is treated with both insulin and an injectable
non-insulin antidiabetic drug, assign codes
Z79.4, Long-term (current) use of insulin,
therapy. If the patient is treated with both oral
hypoglycemic drugs and an injectable non-
insulin antidiabetic drug, assign codes Z79.84,
Long-term (current) use of oral hypoglycemic
drugs, and Z79.899, Other long-term (current)
drug therapy. . . .
6) Secondary diabetes mellitus . . .

Secondary diabetes mellitus and the use of
insulin or oral hypoglycemic drugs . . .
If the patient is treated with both oral medications
and insulin, only the code for long-term (current)
use of insulin should be assigned. If the patient

is treated with both insulin and an injectable
non-insulin antidiabetic drug, assign codes
Z79.4, Long-term (current) use of insulin,
therapy. If the patient is treated with both oral
hypoglycemic drugs and an injectable non-
insulin antidiabetic drug, assign codes Z79.84,
Long-term (current) use of oral hypoglycemic
drugs, and Z79.899, Other long-term (current)
drug therapy. Code Z79.4 should not be
assigned if insulin is given temporarily to bring a
secondary diabetic patient’s blood sugar under
control during an encounter.
5. Chapter 5: Mental, Behavioral and

Neurodevelopmental disorders (F01 – F99) . . .
b. Mental and behavioral disorders due to

psychoactive substance use . . .
3) Psychoactive Substance Use, Unspecified . . .

As with all other unspecified diagnoses, the codes
for unspecified psychoactive substance use
(F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-,
F16.9-, F18.9-, F19.9-) should only be assigned
based on provider documentation and when they
meet the definition of a reportable diagnosis (see
Section III, Reporting Additional Diagnoses).
These codes are to be used only when the
psychoactive substance use is associated with a
physical disorder included in chapter 5 (such
as sexual dysfunction and sleep disorder),
or a mental or behavioral disorder, and such a
relationship is documented by the provider.

9. Chapter 9: Diseases of the Circulatory System
(I00-I99) . . .
a. Hypertension . . .
2) Hypertensive Chronic Kidney Disease . . .

If a patient has hypertensive chronic kidney
disease and acute renal failure, an additional
code for the acute renal failure is required.
should also be coded. Sequence according
to the circumstances of the admission/
encounter.
3) Hypertensive Heart and Chronic Kidney Disease

...
For patients with both acute renal failure and
chronic kidney disease, an additional code
for the acute renal failure is required should
also be coded. Sequence according to the
circumstances of the admission/encounter. . . .
10. Chapter 10: Diseases of the Respiratory System

(J00-J99), U07.0
e. Vaping-related disorders
For patients presenting with condition(s) related
to vaping, assign code U07.0, Vaping-related
disorder, as the principal diagnosis. For lung
injury due to vaping, assign only code U07.0.
Assign additional codes for other manifestations,
such as acute respiratory failure (subcategory
J96.0-) or pneumonitis (code J68.0).
Associated respiratory signs and symptoms due

to vaping, such as cough, shortness of breath,
etc., are not coded separately, when a definitive
diagnosis has been established. However, it
would be appropriate to code separately any
gastrointestinal symptoms, such as diarrhea and
abdominal pain. . . .

14. Chapter 14: Diseases of Genitourinary System
(N00-N99)
a. Chronic kidney disease
1) Stages of chronic kidney disease (CKD)

The ICD-10-CM classifies CKD based on severity.
The severity of CKD is designated by stages
1-5. Stage 2, code N18.2, equates to mild CKD;
stage 3, codes N18.3, equates 30-N18.32,
equate to moderate CKD; and stage 4, code
N18.4, equates to severe CKD. Code N18.6, End
stage renal disease (ESRD), is assigned when
the provider has documented end-stage renal
disease (ESRD). . . .
15. Chapter 15: Pregnancy, Childbirth, and the

Puerperium (O00-O9A) . . .
k. Puerperal sepsis . . .
Code O85 should not be assigned for sepsis

following an obstetrical procedure (See Section
I.C.1.d.5.b., Sepsis due to a postprocedural
infection). . . .
s. COVID-19 infection in pregnancy, childbirth, and

the puerperium
During pregnancy, childbirth or the puerperium,

when COVID-19 is the reason for admission/
encounter , code O98.5-, Other viral diseases
complicating pregnancy, childbirth and the
puerperium, should be sequenced as the
principal/first-listed diagnosis, and code U07.1,
COVID-19, and the appropriate codes for
associated manifestation(s) should be assigned
as additional diagnoses. Codes from Chapter 15
always take sequencing priority.

If the reason for admission/encounter is
unrelated to COVID-19 but the patient tests
positive for COVID-19 during the admission/
encounter, the appropriate code for the reason
for admission/encounter should be sequenced
as the principal/first-listed diagnosis, and codes
O98.5- and U07.1, as well as the appropriate
codes for associated COVID-19 manifestations,
should be assigned as additional diagnoses.
16. Chapter 16: Certain Conditions Originating in the

Perinatal Period (P00-P96). . .
a. General Perinatal Rules . . .
5) Birth process or community acquired

conditions . . .

For COVID-19 infection in a newborn, see

guideline I.C.16.h.
h. COVID-19 Infection in Newborn
For a newborn that tests positive for COVID-19,

assign code U07.1, COVID-19, and the
appropriate codes for associated manifestation(s)
in neonates/newborns in the absence of
documentation indicating a specific type of
transmission. For a newborn that tests positive
for COVID-19 and the provider documents the
condition was contracted in utero or during
the birth process, assign codes P35.8, Other
congenital viral diseases, and U07.1, COVID-19.
When coding the birth episode in a newborn
record, the appropriate code from category Z38,
Liveborn infants according to place of birth
and type of delivery, should be assigned as the
principal diagnosis.

18. Chapter 18: Symptoms, signs, and abnormal clinical
and laboratory findings, not elsewhere classified
(R00-R99) . . .
e. Coma scale
The coma scale codes (R40.2-) can be used in

conjunction with traumatic brain injury codes,
acute cerebrovascular disease or sequelae of
cerebrovascular disease codes. These codes are
primarily for use by trauma registries, but they
may be used in any setting where this information
is collected. The coma scale may also be used to
assess the status of the central nervous system for
other non-trauma conditions, such as monitoring
patients in the intensive care unit regardless of
medical condition. The coma scale codes should be
sequenced after the diagnosis code(s). . . .
21. Chapter 21: Factors influencing health status and

contact with health services (Z00-Z99) . . .
c. Categories of Z Codes
1) Contact/Exposure
Category Z20 indicates contact with, and
suspected exposure to, communicable diseases.
These codes are for patients who do not show
any sign or symptom of a disease but are
suspected to have been exposed to it a disease
by close personal contact with an infected
individual or are in an area where a disease is
epidemic.
Status . . .
The status Z codes/categories are . . .
Z79 Long-term (current) drug therapy

Codes from this category indicate a patient’s
continuous use of a prescribed drug
(including such things as aspirin therapy)
for the long-term treatment of a condition
or for prophylactic use. It is not for use for
patients who have addictions to drugs. This
subcategory is not for use of medications
for detoxification or maintenance programs
to prevent withdrawal symptoms in patients
with drug dependence (e.g., methadone
maintenance for opiate dependence). Assign
the appropriate code for the drug use, abuse,
or dependence instead. . . .
6) Observation . . .
The observation codes are primarily to be
used as a principal/first-listed diagnosis only.
The only exception. An observation code
may be assigned as a secondary diagnosis
code when the patient is being observed for a
condition that is ruled out and is unrelated to
this is the principal/first-listed diagnosis (e.g.,
patient presents for treatment following injuries
sustained in a motor vehicle accident and is
also observed for suspected COVID-19 infection
that is subsequently ruled out). Also, when the
principal diagnosis is required to be a code
from category Z38, Liveborn infants according
to place of birth and type of delivery. Then,
then a code from category Z05, Encounter
for observation and evaluation of newborn for
suspected diseases and conditions ruled out, is
sequenced after the Z38 code. . . .
16) Z Codes That May Only be Principal/First-

Listed Diagnosis . . .
Z03 Encounter for medical observation for

suspected diseases and conditions ruled out
22. Chapter 22: Codes for Special Purposes (U00-U85)
U07.0 Vaping-related disorder (see Section

I.C.10.e., Vaping-related disorders)
U07.1 COVID-19 (see Section I.C.1.g.1., COVID-19
infection)

CHANGES TO THE ICD-10-PCS OFFICIAL
GUIDELINES FOR CODING AND REPORTING
A summary of the modifications to the ICD-10-PCS Official Guidelines
for Coding and Reporting is included below. The complete guidelines
may be downloaded by visiting https://www.cms.gov/medicare/icd-
10/2021-icd-10-pcs.
The modifications are published below using the following format:
Narrative changes appear in bold text (e.g., a more definitive root

operation). Items underlined were moved within the guidelines since
October 1, 2020 (e.g., control of acute bleeding). Deletions are shown
as strikeouts (e.g., any of the definitive root operations).
Medical and Surgical Section Guidelines (section 0)
B3. Root Operation . . .
B3.1b
Exceptions: Mastectomy followed by breast reconstruction, both
resection and replacement of the breast are coded separately. . . .
B3.10c . . .
• If an interbody fusion device is used to render the joint
immobile (alone or containing other material like bone graft
or bone graft substitute), the procedure is coded with the
device value Interbody Fusion Device. . . .
Excision/Resection followed by replacement

B3.18
If an excision or resection of a body part is followed by a
replacement procedure, code both procedures to identify
each distinct objective, except when the excision or resection
is considered integral and preparatory for the replacement
procedure.
Examples: Mastectomy followed by reconstruction, both

resection and replacement of the breast are coded to fully
capture the distinct objectives of the procedures performed.
Maxillectomy with obturator reconstruction, both excision and

replacement of the maxilla are coded to fully capture the distinct
objectives of the procedures performed. Excisional debridement
of tendon with skin graft, both the excision of the tendon and the
replacement of the skin with a graft are coded to fully capture the
distinct objectives of the procedures performed. Esophagectomy
followed by reconstruction with colonic interposition, both the
resection and the transfer of the large intestine to function as the
esophagus are coded to fully capture the distinct objectives of
the procedures performed.
Examples: Resection of a joint as part of a joint replacement

procedure is considered integral and preparatory for the
replacement of the joint and the resection is not coded
separately. Resection of a valve as part of a valve replacement
procedure is considered integral and preparatory for the valve
replacement and the resection is not coded separately . . . .
B5. Approach . . .
Open approach with percutaneous endoscopic assistance

B5.2a . . .
Percutaneous endoscopic approach with extension of incision

B5.2b
Procedures performed using the percutaneous endoscopic
approach, with incision or extension of an incision to assist in
the removal of all or a portion of a body part or to anastomose
a tubular body part to complete the procedure, are coded to the
approach value Percutaneous Endoscopic.
Examples: Laparoscopic sigmoid colectomy with extension of

stapling port for removal of specimen and direct anastomosis is
coded to the approach value percutaneous endoscopic.
Laparoscopic nephrectomy with midline incision for removing

the resected kidney is coded to the approach value percutaneous
endoscopic.
Robotic-assisted laparoscopic prostatectomy with extension

of incision for removal of the resected prostate is coded to the
approach value percutaneous endoscopic.

Frequently Asked Questions Regarding
ICD-10-PCS Coding for COVID-19
Revised September 1, 2020
The following questions and answers were jointly developed and

approved by the American Hospital Association’ Central Office on
ICD-10-CM/PCS and the American Health Information Management
Association.
Question:
Should the administration of remdesivir,
sarilumab, or tocilizumab be coded each time it
is administered during a hospitalization or just
coded once?
Answer:
Only assign the drug administration code once.
Question:
What ICD-10-PCS code should be assigned for
the administration of Dexamethasone (either
orally or intravenously) when it is being used to
treat COVID-19?
Answer:
If your facility wishes to capture this information,
you may assign the appropriate code from table
3E0 for introduction of an anti-inflammatory
drug. Do not assign a code from table XW0
for Introduction of Other New Technology
Therapeutic Substance.

Ask the Editor
Question:
An elderly female was admitted to the intensive
care unit due to acute hypoxemic respiratory
failure. During the hospitalization, the patient
required high flow nasal cannula and BIPAP;
however, despite these aggressive measures
her respiratory status continued to decline,
requiring intubation and mechanical ventilation.
In the final diagnostic statement, the provider
listed “Acute respiratory distress syndrome
(ARDS).” Is ARDS considered a progression
of the respiratory failure or a distinct clinical
condition? What ICD-10-CM code and present
on admission (POA) indicator should be
assigned for a patient who is admitted in acute
hypoxic respiratory failure that progresses to
ARDS?
Answer:
Assign code J80, Acute respiratory distress
syndrome, for acute hypoxic respiratory failure
that progresses to ARDS. Per the Excludes 1
note under category J96, only code J80 should
be assigned when respiratory failure and ARDS
are both documented. Assign the POA indicator
“Y” for the ARDS, since the patient experienced
deterioration and worsening of her respiratory
condition. ARDS is a life-threatening form
of respiratory failure and is not an unrelated
condition. When acute respiratory failure is
documented along with ARDS, only one code is
reported to capture the highest level of severity
with a POA indicator of “Y.”
As previously published in Coding Clinic Fourth

Quarter 2017, page 23, “Acute respiratory
distress syndrome (ARDS) is a life-threatening
condition. ARDS is a rapidly progressive
disorder that has symptoms of dyspnea,

tachypnea, and hypoxemia. Fluid builds up in
the alveoli and lowers the amount of oxygen
that is circulated through the bloodstream.
Low levels of oxygen in the blood threatens
organ function. ARDS is often associated with
sepsis, pneumonia, trauma and aspiration.
The majority of people who develop ARDS are
already in the hospital in critical condition from
some other health complication. The focus of
treatment is getting oxygen to the organs.”
Question:
A 68-year-old male was admitted due
to anemia. The patient also has a past
medical history of HIV disease, currently on
antiretrovirals (ARVs). The patient had a history
of CD4 count less than 200 with a current CD4
of 335. The provider’s diagnostic statement
listed, “HIV disease on ARVs (CD4 335, VL
undetectable)” as a secondary diagnosis. What
is the appropriate HIV code for this patient?
Answer:
Assign code B20, Human immunodeficiency
virus [HIV] disease, for this patient. The
provider documented HIV disease, which
is specifically classified to code B20. As
with any other condition, query the provider
for clarification when there is conflicting
documentation.
Question:
A 55-year-old with a personal history of
end-stage renal disease (ESRD) and long-
standing history of HIV disease presented
due to influenza. The provider documented
HIV disease on current treatment with a CD4
level over 1,000 and an undetectable viral
load. What is the appropriate HIV code for this
patient?

Answer:
Assign code B20, Human immunodeficiency
virus [HIV] disease, for this patient. Provider
documentation indicated HIV disease, which
is specifically classified to code B20. As
with any other condition, query the provider
for clarification when there is conflicting
documentation.
Question:
Should code Z51.5, Encounter for palliative
care, be assigned for patients who do not have
a terminal disease, but are receiving comfort
care for a serious illness?
Answer:
Yes. Code Z51.5, Encounter for palliative
care, should be assigned in any palliative
care situation. This code assignment is not
limited to end of life (terminal) care. Palliative
care can involve treatment of patients with a
serious illness, which is different from end of
life (hospice) care, where the patient is not
expected to live beyond six months.
Question:
Please clarify correct code assignment for
critical limb ischemia. There are no entries in
the Index to Diseases for this condition and
coding professionals may arrive at different
codes. The Index entry for ischemia is I99.8,
Other disorder of circulatory system.
Answer:
Critical limb ischemia (CLI), also known as
chronic limb-threatening ischemia (CLTI),
is a severe form of atherosclerosis of the
extremities with rest pain, ulceration, and/or
gangrene. Effective October 1, 2020, there
are new inclusion terms in the Tabular list
within category I70, Atherosclerosis, to identify
codes for critical limb ischemia. There are

also extensive new subentries in the Index
to direct users to category I70. Critical limb
ischemia without further specificity is coded to
atherosclerosis of the extremities with rest pain.
Question:
ICD-10-CM Official Coding and Reporting
Guidelines for coding COVID-19 (April 1, 2020
through September 30, 2020 version) used
to allow coding of confirmed cases on the
basis of “presumptive test results.” Is that no
longer allowed with the FY 2021 version of the
guidelines?
Answer:
A presumptive positive test result means an
individual has tested positive for the virus at
a local or state level, but it has not yet been
confirmed by the Centers for Disease Control
and Prevention (CDC). Since CDC confirmation
of local and state tests for COVID-19 is no
longer required, “presumptive positive results”
was removed from the guidelines as a method
of confirming a diagnosis of COVID-19 for
coding purposes.
Question:
A patient with prostate cancer presents for a
robotic-assisted laparoscopic prostatectomy.
Pneumoperitoneum was established and the
abdomen was insufflated. The robotic trocars
were then placed in the standard configuration,
and the robot was docked. The dissection was
carried bluntly around to the anterior prostate
and bladder neck. The bladder neck was
divided sharply. The apex of the prostate was
freed sharply and the urethra divided. The robot
was then undocked. All laparoscopic ports
were removed under direct vision. The midline
incision was lengthened to allow extraction of
the specimen. What is the appropriate ICD-10-
PCS approach value when the prostate was

detached from surrounding structures using a
percutaneous endoscopic approach, however
an incision was made to remove the specimen
from the patient’s body?
Answer:
Assign the approach value “4, percutaneous
endoscopic” for the robotic-assisted
laparoscopic prostatectomy. In this case,
surgery was performed laparoscopically; at the
end of the procedure, the midline incision was
extended to assist in removing the specimen
(prostate). According to the new ICD-10-PCS
guideline B5.2b, “Procedures performed using
the percutaneous endoscopic approach, with
incision or extension of an incision to assist in
the removal of all or a portion of a body part or
to anastomose a tubular body part to complete
the procedure, are coded to the approach value
Percutaneous Endoscopic.”
An important factor in assigning the correct

approach value in ICD-10-PCS is to determine
what structures were detached and how
they were detached based on the medical
record documentation. The focus should be
on the surgical technique or approach used
for the detachment of those structures. Code
assignment should not be based on the location
or approach of where the structures were
physically removed from the patient’s body.
Question:
This patient was found to have a large
tubulovillous adenoma with focal high-grade
dysplasia and presented for a laparoscopic
robotic-assisted sigmoid colectomy with primary
anastomosis. The procedure was started with
an Optiview trocar technique to the right of the
umbilicus. The abdomen was insufflated and
the camera was introduced. The Da Vinci robot
was brought to the table where it was docked

into port in the usual fashion. Once the colon
was completely mobilized, a linear endoscopic
stapling device was then used to divide the
colon at this point. The stapling port site at
the umbilicus was extended slightly so that
the specimen could be removed. The wound
protector device was placed and the specimen
was removed through the port without difficulty.
The stapled end of the descending colon was
then brought up through the wound protector
device at skin level where it was prepared
for anastomosis. A purse-string suture was
placed above the staple line and the staple
line amputated sharply with scissors. The
descending colon was serially dilated to
approximately 30 mm. The stapler was placed
within the lumen and secured with a purse-
string and placed back within the abdominal
cavity. This port site incision was then closed.
What is the appropriate ICD-10-PCS approach
value when the colon was divided using a
percutaneous endoscopic approach, however
an incision was made to remove the specimen
from the patient’s body and complete the
anastomosis?
Answer:
Assign the approach value “4, percutaneous
endoscopic” for the robotic-assisted sigmoid
colectomy with primary anastomosis. In this
case, surgery was performed laparoscopically;
at the end of the procedure, stapling port was
then extended so that the specimen could
be removed and the direct anastomosis was
completed through the open incision. According
to the new ICD-10-PCS guideline B5.2b,
“Procedures performed using the percutaneous
endoscopic approach, with incision or extension
of an incision to assist in the removal of all or
a portion of a body part or to anastomose a
tubular body part to complete the procedure,
are coded to the approach value Percutaneous
Endoscopic.”


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A quarterly publication of the

Central Office on ICD-10-CM/PCS

2 Fourth Quarter 2020 Coding Clinic

Coding Clinic Fourth Quarter 2020 3

There are 490 new ICD-10-CM codes effective October 1, 2020. In

Powassan (POW) Virus Disease

Subcategory A84.8, Other tick-borne viral encephalitis, was expanded

Powassan (POW) virus disease is a tick-borne zoonosis caused

4 Fourth Quarter 2020 Coding Clinic

Code B60.0, Babesiosis, was expanded and new codes created

As the majority of Babesia infections are presumed to be

The addition of species-specific Babesia coding will enable the Food

Coding Clinic Fourth Quarter 2020 5

Codes were created in category D57, Sickle-cel disorders, to identify

Cerebral infarct and cerebral ischemia are major complications in

In addition, codes were created in subcategory D57.4, Sickle-cell

• Without crisis (D57.42, D57.44),

In addition to the abnormal sickle shape of the red blood cells

6 Fourth Quarter 2020 Coding Clinic

Acquired Autoimmune Hemolytic Anemias

Code D59.1, Other autoimmune hemolytic anemias, was expanded

• D59.10 Autoimmune hemolytic anemia, unspecified

Acquired autoimmune hemolytic anemia (AIHA) occurs when

Warm hemolysis, the most common type of temperature-sensitive

Coding Clinic Fourth Quarter 2020 7

In cold hemolysis or cold agglutinin disease, immunoglobulin M (IgM)

A person with mixed type autoimmune hemolytic anemia has severe

Hypereosinophilic Syndromes and Other

D72.10 Eosinophilia, unspecified

8 Fourth Quarter 2020 Coding Clinic

Lymphocytic variant hypereosinophilic syndrome (LHES) is

Drug rash with eosinophilia and systemic symptoms (DRESS)

Idiopathic hypereosinophilic syndrome (IHES) accounts for 70%

Coding Clinic Fourth Quarter 2020 9

New codes were created to report specific causes for a patient’s

Code D84.821, Immunodeficiency due to drugs, was created

10 Fourth Quarter 2020 Coding Clinic

Multiple codes may be assigned to show immunodeficiency due

In this case, the immunosuppressant

Coding Clinic Fourth Quarter 2020 11

Cytokine Release Syndrome

12 Fourth Quarter 2020 Coding Clinic

Grade 1 CRS (D89.831) includes low grade fever with or without

Grade 2 CRS (D89.832) is a moderate reaction that includes fever

Grade 3 CRS (D89.833) includes fever with hypotension requiring

Grade 4 CRS (D89.834) includes fever with hypotension requiring

Grade 5 CRS (D89.835) is defined as death due to CRS.

Unspecified CRS is assigned to code D89.839.

Additionally, at the time of publication, more and more clinical data

Coding Clinic Fourth Quarter 2020 13

14 Fourth Quarter 2020 Coding Clinic

Aromatic L-Amino Acid Decarboxylase Deficiency

Code E70.81, Aromatic L-amino acid decarboxylase deficiency,

There is no cure for AADC deficiency. Early diagnosis is critical to

Coding Clinic Fourth Quarter 2020 15

Glucose Transporter Deficiencies

Codes have been created for deficiencies in glucose transport:

• E74.810 Glucose transporter protein type 1 deficiency

Glucose transporter protein type 1 deficiency syndrome (Glut1DS) is

Glut1DS is an epileptic encephalopathy that is associated with

Withdrawal Syndrome in Substance Use and Abuse

Codes were created for withdrawal in psychoactive substance

16 Fourth Quarter 2020 Coding Clinic