Part 1: New ICD Codes and IPPS Changes for 2021

This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS.  In this part, we discuss some of  the new ICD-10-CM diagnosis changes.

Here is the breakdown:

  • 72,616 total ICD-10-CM codes for FY2021
  • 490 new codes (2020 had 273 new codes)
  • 58 deleted codes (2020 had 21 deleted codes)
  • 47 revised codes (2020 had 30 revised codes)

Most of the changes occurred in the injuries, poisonings, and consequences of external causes, external causes of morbidity and musculoskeletal system chapters.  I have to say that there were really no big earthshattering changes.  If there was a “theme” for this year’s changes, it would be “expansion of existing codes to more specific codes.”  The major changes will be discussed below.


Chapter 3: Diseases of blood and blood forming organs and immune mechanism (D50-D89)

The first big change involves expansion of the D57 Sickle-cell disorders.  These codes now identify if each type of sickle cell disease with crisis and if there is cerebrovascular involvement or other specified complications. Coders would code also the specific complication.  This applies to D57.0- HB-SS disease with crisis, D57.2- Sickle-cell/HB-C disease with crisis, D57.4- Sickle-cell thalassemia, divided out to identify beta ZERO with and without crisis and beta PLUS with and without crisis and of course “other” sickle-cell disorders.  For the latter Sickle-Cell codes, there are code additions for with “splenic sequestration” or “acute chest syndrome.”  Acute chest syndrome causes pain, cough, fever, hypoxia and lung infiltrates.  It is the result of sickling in the small blood vessels of the lungs causing pulmonary infarction or emboli and can cause bacteria pneumonia.

Splenic sequestration (blood trapped in the spleen) refers to a sudden condition of pooling of large amounts of blood in the spleen. Children with sickle cell disease between ages five months and two years represent most cases of splenic sequestration.  Treatment is blood volume expanders and blood transfusion to reverse hypovolemic shock. Coders will need to dig into documentation for physician identification of sickle-cell type and any manifestations in order to assign the correct codes.

Similar changes were made to other codes in the chapter:

  • D59.1 Other autoimmune hemolytic anemias was expanded to address all of the different types of these anemias, D59.10-D59.19 that were once all contained under code D59.1 only.
  • D72.1, Eosinophilia has been expanded to codes D72.10-D72.19 to accommodate the specific types of Eosinophilia that were once only included under D72.1.
  • D84.8 for other specified immunodeficiencies has been expanded to D84.81-D84.89 for specific types of immunodeficiencies such as those due to drugs or external causes, once contained under D84.8.
  • D89.83 Cytokine release syndrome has been expanded to D89.831-D89.839 to identify the grade 1-5 or unspecified.  There is a “code first” note at D89.83-  for underlying cause that coders will have to follow along with “Use additional code” for any manifestations.

The Excludes1 note to exclude neutropenia (D70.1) under D61, aplastic anemias has now been changed to an Excludes2 note. So coders can now report neutropenia with aplastic anemia if applicable.


Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders (F01-F99)

New codes were added for alcohol abuse with withdrawal and various withdrawal symptoms  (F10.130-F10.139 and alcohol use with withdrawal and various withdrawal symptoms (F10.930-F10.939.) The same was done for codes involving opioid abuse, cannabis abuse and sedative, hypnotic or anxiolytic-related abuse.   Coders have seen these alcohol/drug “Use’ or “Abuse” diagnoses documented with withdrawal, but there was no way in the past to code these.  Clinically, it was originally thought that a withdrawal syndrome only developed in individuals with a diagnosis of substance dependence; however, substance withdrawal can occur in clinical situations involving individuals who use substances regularly and then suddenly stop using them, but who do not have a diagnosis of substance dependence.


Chapter 6: Nervous System (G00-G99)

Hereditary ataxia, G11.1 has been expanded to several different types, G11.10-G11.19.

A “Use additional code” note has been added under G20 Parkinson’s disease to let coders know to report dementia with or without behavioral disturbance (F02.81 or F02.80)

Two new codes were added for epilepsy; G40.42 for Cyclin-Dependent Kinase-Like 5 Deficiency Disorder and G40.833, G40.34, Dravet syndrome, intractable, with or without status epilepticus

C71.2, Congenital myopathies have been expanded to G71.20-G71.29 so that specific types now have an individual code.

On major change is the addition of new cerebrospinal fluid leak codes. G96.0 has been expanded to the following:

  • G96.00, Cerebrospinal 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

Coders will need to review documentation for the specific site of the leak and if it is spontaneous, postoperative or traumatic of those sites. The index is very helpful in determining correct codes by site.

There are also expanded codes for G96.191, Perineural or Tarlov cyst an d G96.198, Other disorders of meninges.

G96.81, Intracranial hypotension was expanded to three codes G96.810, G96.811 and G96.819 to identify unspecified, spontaneous or other intracranial hypotension.  New codes G97.83, intracranial hypotension following lumbar cerebrospinal fluid shunting and G97.84, Intracranial hypotension following other procedure was added. A code also note follows G97.84.


Chapter 9: Circulatory System (I00-I99)

A big change is the changing of the Excludes1 note for cardiogenic shock under I46, Cardiac arrest to an Excludes2 note. This means that cardiogenic shock can now be reported with cardiac arrest.  HIA is sending a case to AHA to see if both can be coded if both are related to the same issue.

All of the atherosclerosis codes in I70.2- of native arteries of the extremities now include “chronic limb-threatening ischemia and critical limb ischemia” within the codes. Coders may see the abbreviation of “CLTI.”


Chapter 10: Respiratory System (J00-J99)

Many of the excludes notes where changed or added especially in regards to influenza virus with other respiratory manifestations. Code also, influenza notes were added to codes J04, Acute laryngitis and tracheitis and J05 Acute obstructive laryngitis [croup].  Many Excludes1 notes were changed to Excludes2 notes.   Coders need to read these notes in the tabular to be sure they are assigning codes involving influenza and other diagnoses appropriately.

J82.8, Pulmonary eosinophilia was expanded to identify specific types of eosinophilia.

J84.1, Other interstitial pulmonary diseases with fibrosis was expanded to identify specific interstitial lung disease.  Code first notes were added throughout.


Chapter 11: Digestive System (K00-K95)

Codes K20.8, Other esophagitis and K20.9, Esophagitis, unspecified have been expanded to identify these condition without bleeding or with bleeding. This aligns with how other diagnoses are depicted in this chapter.

K74.0, Hepatic fibrosis has been expanded to include hepatic fibrosis by stage.  Also a “Code first underlying liver disease” note applies to this subcategory.  These are the stages that now can be coded:

The Metavir system also scores the level of fibrosis from F0 to F3:

  • F0: an absence of fibrosis
  • F1: portal fibrosis with no septa
  • F2: portal fibrosis with infrequent septa
  • F3: numerous septa but no cirrhosis
  • F4: cirrhosis  (Code to cirrhosis, K74.6-)
    • Cirrhosis is scar tissue building up in the liver. This can occur due to unchecked fibrosis.


Chapter 14: Genitourinary System (N00-N99)

Code N00, Acute nephritis syndrome was expanded to accommodate N00.6, Acute nephritic syndrome with dense deposit disease and N00.A, Acute nephritic syndrome with C3 glomerulonephritis.  These diagnoses were also added to N01.- Rapidly progressive nephrotic syndrome, N02.- Recurrent and persistent hematuria, N03.- Chronic nephritic syndrome; N04.- Nephrotic syndrome; N05.- Unspecified nephrotic syndrome; N06- Isolated proteinuria and N07.- Hereditary nephropathy.

C3 glomerulonephritis (C3GN) is a recently described entity that shows a glomerulonephritis on light microscopy (LM), bright C3 staining and the absence of C1q, C4 and immunoglobulins (Ig) on immunofluorescence microscopy (IF), and mesangial and/or subendothelial electron dense deposits on electron microscopy (EM). The “C3” refers to a blood protein that plays a key role in normal immunity

The term C3G includes dense deposit disease (DDD) and C3 glomerulonephritis (C3GN); these are two patterns of damage and inflammation in the glomeruli. In other words, the damage and inflammation in the kidney tissue in DDD looks different from that in C3GN when seen under a microscope.

N18.3, CKD stage 3 has been expanded by three codes, N18.30, CKD stage 3, unspecified N18.31, CKD stage 3a and N18.32, CKD stage 3b.  Stage 3a is GFR of 45-59 mL/min .  Stage 3b is GFR of 30-44 mL/min

(GFR is the glomerular filtration rate.)


Chapter 18: Symptoms, sings, abnormal findings (R00-R99)

The Excludes1 note at R51, Headache for facial pain, migraine and trigeminal neuralgia has been changed to an Excludes2 note.  Coders can now report both codes if appropriate.  Also R51 has been expanded to two new codes; R51.0, Headache with orthostatic component, NEC and R51.9, Headache, unspecified.

R74.0, Nonspecific elevation of transaminase and LDH has been expanded to R74.01, Elevation of levels of liver transaminase levels and R74.02, Elevation of levels of lactic acid dehydrogenase [LDH].   This is a welcome change in that elevations of different enzymes included in these codes can result in different  clinical treatment modalities and resource utilization. For example, an elevation in liver transaminases in a trauma patient could indicate the need for at CT scan looking for solid tissue injury; while an elevation in LDH could indicate a neoplastic condition.

The FY2021 Official Guidelines for Coding and Reporting made  change that was not clearly evident in the updated guidelines. This was not evident in Coordination and Maintenance Committee meeting materials or made clear on the FY2021 OCG document.  Below you will see that the lines for using the coma scale codes for “acute cerebrovascular disease or sequelae of cerebrovascular disease codes”  and “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.”  have been removed for the Glasgow coma scale code guidelines regarding coma scale code assignment. This indicates that the Glasgow coma scale codes should be used in conjunction with traumatic brain injury codes only beginning with discharges October 1, 2020.   AHA has stated the change was made to revert back to the original intent of the GCS codes, in that they originally were meant to be used for TBI cases only.

 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).

These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes.


Chapter 19: Injury, Poisoning, Consequences of External Cause (S00-T88)

For S02.2  Contusion of thorax; S20.3 other superficial injuries of front wall of thorax,  new codes were added for “bilateral front wall of thorax” and “middle front wall of thorax”

All codes for T40.4X1-T40.4X6 for poisoning, adverse effect or underdosing of other synthetic narcotics were deleted, adding it back later in T40.49-.  New codes for poisoning, adverse effect and underdosing of Tramadol, T40.42- and other synthetic narcotics, T40.49- added. 


Chapter 20: External Causes (V00-Y99)

Added new external cause codes for injuries due to pedestrian conveyance accident, standing electric scooter;  and standing micro-mobility pedestrian conveyance (SEGWAY) (Hoverboard)  vehicle.

They added contact lens and other ophthalmic devices associated with adverse incident as new external cause codes Y77.11 and Y77.19 


Chapter 20: External Causes (V00-Y99)

New Z codes were added for Encounter for observation for suspected foreign body ruled out. Individual codes now include those for ingested, aspirated, or inserted FB ruled out in codes Z03.821-Z03.823.


Official Guidelines for Coding and Reporting

There were not as many changes this year to official coding guidelines.  For B. General coding guidelines, 14. Documentation by clinicians other than the patient’s provider, the following statement was added:  “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.” 

All of the COVID-19 guidelines have been added to the OCG under section 1. Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), U07.1; g. Coronavirus infections (New).  These are primarily from the FAQs that we received from AHA throughout the pandemic.   COVID-19 updates were also added to the Obstetrics and Neonatal guidelines. 

In the Chapter 4 Endocrine, Nutritional and Metabolic Disease, the following was added regarding diabetic drug administration:  “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, and Z79.899, Other long term (current) drug 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.”

Injectable non-insulin anti-diabetic drugs:

  • Liraglutide (Victoza) once daily injection
  • Exenatide (Byetta) twice daily injection
  • Exenatide extended release pen (Bydureon) once weekly injection
  • Albigltide (Tanzeum) once weekly injection
  • Dulaglutide (Trulicity) once weekly injection

Non-insulin injectable medications mimic the effect of the body’s own ‘incretin hormones’ which help to manage blood glucose levels after meals.

For Chapter 9: Diseases of the Circulatory System, 3) Hypertensive Heart and Chronic Kidney Disease, the bolded words were added:  For patients with both acute renal failure and chronic kidney disease, “the acute renal failure should also be coded. Sequence according to the circumstances of the admission/encounter.”

 There is a new guideline “e. Vaping-related disorders” in Chapter 10 for Diseases of the Respiratory System.

Finally, this was added to Chapter 21: Factors influencing health status in 6) Observation section:  “The observation codes are primarily to be used as a principal/first-listed diagnosis. 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 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).”

In Part 2 of this series, we will look at some highlights of the new ICD-10-PCS codes and changes.

The information contained in this post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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