In September, my IMO colleagues and I hosted a webinar about the ICD-10-CM 2020 updates and regulatory readiness process. Our talk allowed us to discuss the details of many of the 273 additions, 23 deletions and 30 code title revisions that took effect on October 1. While these details are critical to ensuring that healthcare providers are prepared for the changes, the annual updates are also a time to take a look at the larger picture of healthcare and see how new changes reflect the current medical landscape.

Keeping up with the clinical

Since medical knowledge is always evolving, it’s important to have a code system that is able to grow along with it. With the ICD-10-CM, the annual review and update process is our way of making sure the codes continue to support the needs of healthcare providers. The annual updates ensure the system is streamlined and useable, whether that is through pure index changes or by adding new information about different diseases as we learn more about them.

This year, there are a few examples of simple, but helpful, index changes, such as the updates affecting the ascending colon, descending colon and the cecum. Previously, polyps in these colonic areas were automatically classified as adenomatous if further morphology could not be specified. The 2020 index changes require the provider to specify the colon polyp’s morphology as adenomatous. If the provider documents a hyperplastic colon polyp, the new index entry classifies the polyp to K63.5 regardless of the site.

Organizationally, code updates are also important to help providers capture specificity and nuance within their diagnoses. A common example of this is when details like laterality are added to the system. This year, congenital chapter codes within the Q66 subcategory, along with unspecified breast lumps (N63) are two of the sections of code now offering options for laterality. New codes were also created to identify when a breast lump is located in overlapping quadrants.

We also see clarification with the new code, R82.81, which establishes pyuria as a distinct classifiable condition. The system no longer makes the assumption that presence of white blood cells (WBC) equates to a urinary tract infection (UTI). Although this is often true, the reclassification allows for increased subtlety in coding the two conditions.

Advancing with science

But the key piece is that the annual updates to the codes allow the classification system to keep up with major changes in medicine. For example, as we discover more about different diseases that have a genetic basis, the system is now able to more accurately capture such disorders. This year’s changes to the congenital condition and syndrome codes reflects this advancement.

For example, Ehlers-Danlos Syndrome was previously represented by a single code, Q79.6. October’s updates expand the code system to Q79.60-Q79.69, further specifying the common and more severe types of this condition. Specific additions include codes for classical, hypermobile and vascular forms of Ehlers-Danlos. The inclusion of these distinctions is significant, when comparing the vascular and hypermobile types, specifically. Those with hypermobile Ehlers-Danlos Syndrome have joints that can extend farther than normal, appearing to be “double-jointed”. This manifestation of the disease is relatively benign when compared with the vascular expression, whose symptoms include rupture of the arteries and intestines.

Continuing the trend of increasing specificity, the D81.3 subcategory has also expanded. Within the Disease of the Blood and Blood Forming Organs chapter, Adenosine Deaminase Deficiency (ADA) now has codes for type 1 and type 2 ADA. This change allows clinicians to indicate the different ADA types. Type 1 ADA carries a risk of severe combined immunodeficiency (SCID). The code changes distinguish type 1 ADA patients who have SCID with code D81.31. 

Finally, some code shifts allow us to be consistent with other manuals and guidelines. Mild tobacco use disorder is now directed to the F-codes. This indexing change aligns the DSM-5 and ICD-10-CM, supporting the consistency between the two systems. Additionally, patients presenting with delirium will no longer be automatically assigned a code within the F chapter. Delirium moves into the R-code classification.

Overall, this year’s code updates reflect medicine’s evolution and define specifically how certain diseases present and progress. Both the maturation of our medical knowledge and the decisions to update the codes in this way indicate that future updates may continue to support more personalized medicine, an exciting development for the field.