The FY 2022 ICD-10-CM Official Guidelines for Coding and Reporting introduced several important changes that medical coders, healthcare providers, and revenue cycle teams needed to understand before the October 1, 2021 implementation date. The updated guidelines provided clarification on documentation, laterality, COVID-19, diabetes, pressure ulcers, coma coding, social determinants of health, and several other areas.
Staying informed about annual ICD-10-CM updates is essential for maintaining coding accuracy, supporting compliant billing, and minimizing claim issues. Below are some of the most important FY 2022 changes.
New Guidance for Laterality
One important update involved laterality, or identifying the affected side of the body. When the provider does not document laterality, coders may use documentation from other clinicians involved in the patient’s care.
However, if medical records contain conflicting information about the affected side, the attending provider should be queried for clarification. Unspecified-side codes should generally be avoided when sufficient documentation can be obtained.
This update highlights the importance of reviewing the complete medical record rather than relying solely on one provider’s documentation.
Documentation From Other Clinicians
The FY 2022 guidelines also clarified when coding information can be obtained from clinicians other than the patient’s provider.
Certain information may be documented by other qualified healthcare professionals, including:
- Body Mass Index (BMI)
- Pressure ulcer stage
- Depth of non-pressure chronic ulcers
- Coma scale
- NIH Stroke Scale (NIHSS)
- Social determinants of health
- Laterality
- Blood alcohol level
For example, a dietitian may document BMI, while a nurse may document the stage of a pressure ulcer.
However, the associated diagnosis must still be documented by the patient’s provider. When documentation conflicts, the attending provider should be queried.
Post-COVID-19 Condition Coding
One of the most notable FY 2022 changes was the introduction of U09.9 – Post COVID-19 condition.
The new guidance addressed patients experiencing ongoing or subsequent conditions related to a previous COVID-19 infection. Coders were provided with additional instructions concerning COVID-19 sequencing, signs and symptoms, follow-up encounters, multisystem inflammatory syndrome, and post-COVID conditions.
As COVID-19 continued to affect healthcare delivery, accurate documentation and coding became increasingly important for patient records and reimbursement.
HIV Coding Updates
Additional guidance was introduced for patients with a documented history of HIV disease who are currently managed with antiretroviral medications.
When HIV disease is documented and the patient is receiving antiretroviral treatment, B20 – Human immunodeficiency virus [HIV] disease should be assigned. Z79.899 – Other long-term (current) drug therapy may also be reported to identify long-term use of antiretroviral medication when appropriate.
New Guidance for Breast Implant-Associated Lymphoma
FY 2022 also introduced specific guidance for Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL).
BIA-ALCL is a type of lymphoma that can develop around breast implants. The guidelines direct coders to assign C84.7A – Anaplastic large cell lymphoma, ALK-negative, breast.
The guidelines also clarify that a complication code from Chapter 19 should not be assigned for this condition.
Diabetes Coding Changes
Several updates were made to the diabetes mellitus guidelines, particularly concerning the use of:
- Insulin
- Oral hypoglycemic medications
- Injectable non-insulin medications
- Secondary diabetes mellitus
These changes reinforce the importance of carefully reviewing the patient’s medical documentation and treatment status before selecting additional medication-related codes.
Accurate diabetes coding can be particularly important because diabetes may be associated with multiple complications and comorbidities.
Pressure Ulcer Coding
The FY 2022 guidelines provided additional clarification for unstageable pressure ulcers.
When an unstageable pressure ulcer is debrided and the actual stage becomes identifiable during the encounter, the coder should assign the code for the stage revealed after debridement.
This clarification helps ensure that the final reported code accurately reflects the documented condition.
Obstetric Coding Clarification
The guidelines also clarified coding when delivery occurs during the current admission.
When an obstetric complication has an “in childbirth” code and delivery occurs during the admission, the “in childbirth” code should be assigned. If the classification does not provide an “in childbirth” option, the appropriate trimester code may be used.
This distinction is important for accurate obstetric diagnosis sequencing and reporting.
Coma and Coma Scale Coding
FY 2022 brought several revisions to coma-related coding guidance.
The updated guidelines clarified that R40.20 – Unspecified coma may be reported with codes for an underlying medical condition. However, unspecified coma and coma scale codes should not be reported for patients experiencing a medically induced coma or who are sedated.
The guidelines also clarified how to report multiple coma scores captured during the first 24 hours after hospital admission. When multiple scores are documented, only the score at the time of admission should be assigned.
Burns and Corrosions
Updates were also made to the guidelines for burns and corrosions classified according to the extent of body surface involved.
Codes from T31 and T32 can provide additional information when the burn or corrosion site is not specified or when additional data is required. However, these codes should not be used for burn or corrosion sequelae.
Accurate documentation of burn severity and body surface involvement remains essential for appropriate coding.
Social Determinants of Health
Another important development was the addition of specific guidance for Social Determinants of Health (SDOH).
Information related to social factors can provide valuable context about a patient’s health and healthcare needs. The FY 2022 guidelines clarified that certain SDOH information may be documented by clinicians other than the patient’s provider.
These codes should generally be reported as secondary diagnoses when applicable.
Immunization Safety Counseling
The guidelines also introduced Z71.85 – Encounter for immunization safety counseling.
This code is intended for counseling patients or caregivers regarding vaccine safety. It should not be used simply to report general information about vaccine risks or potential side effects during routine vaccine administration encounters.
Importance of Accurate ICD-10-CM Coding
The FY 2022 updates demonstrate why medical coding teams must regularly review annual ICD-10-CM guideline changes. Even relatively small wording changes can affect code selection, sequencing, documentation requirements, and reimbursement.
Healthcare organizations should encourage ongoing coder education and maintain strong communication between providers and coding professionals. Complete and consistent documentation is fundamental to accurate diagnosis coding.
How Professional Medical Coding Support Can Help
Keeping up with ICD-10-CM changes can be challenging for busy healthcare organizations. Professional medical coding services can help providers maintain accurate coding practices while reducing errors and supporting compliant reimbursement.
Experienced coding professionals can review documentation, identify appropriate diagnosis codes, follow annual guideline changes, and help healthcare organizations improve their overall revenue cycle.
Final Thoughts
The FY 2022 ICD-10-CM Official Guidelines introduced important changes across multiple coding areas, including laterality, COVID-19, HIV, diabetes, pressure ulcers, coma, obstetrics, burns, immunization counseling, and social determinants of health.
For healthcare providers and medical billing organizations, understanding these updates is essential for maintaining accurate, compliant, and efficient coding practices. Regular training, detailed documentation, and careful review of the official guidelines can help reduce coding errors and support cleaner claims.
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