Industry hot topics: Insight into ambiguous, inconsistent, conflicting advice and guidance

Every month, you will find a new topic or question along with the committee’s findings posted to this page and publicized in CDI Strategies. Please note that the 2020 and 2021 lists appear below the 2022 table. 

2022 hot topic list

Topic Summary Discussion point Date posted
Severity of illness (SOI) comparison The SOI for a newborn (Z38.00) with respiratory distress syndrome (RDS) (P22.0) is lower (ALOS 17.9) than for a newborn with unspecified respiratory distress (P22.9) (ALOS 3.4). 

It is a common misconception that severities across base APR-DRGs can be compared. An SOI value of 2 in one APR-DRG does not necessarily equal an SOI value of 2 in a different APR-DRG. In the 3M encoder, review the Assignment Reports which are available in the Coding & Reimbursement System® via the same-named icon to the left of the APR-DRG text. This report provides the logic used in the SOI/ROM assignments.  

Traumatic periprosthetic fracture Two codes are required to reflect this diagnosis. Coding Clinic, fourth quarter 2016, pp. 42-43, contains instructions for sequencing these codes. The tabular index, however, only has an Excludes 2 note under S72 for M97.0-.

This sequencing has DRG impact. The tabular index has no sequencing instruction and has hierarchy over Coding Clinic

Consider requesting clarification:



Coma Score (GCS) coding Guideline revision with update

Code R40.2- is now limited to TBI cases according to an American Hospital Association (AHA) webinar. If coma scale codes are not permitted for non-traumatic injuries and conditions that alter neurological function, there is a risk of inaccurate or incomplete reflection of the clinical picture. The severity of illness, length of stay, and resource utilization are impacted by decreased GCS, or coma, that is not medically induced but is a result of the non-traumatic injury or condition. 

Although Coding Clinic, fourth quarter 2020, p. 91, reflects the revision of the coma scale guideline, clear definitive guidance would be helpful for clarity of use, including unspecified coma. The current guideline notes that they can be used in conjunction with TBI codes. However, it does not specifically state that they are not permitted for use in other cases. Specific clarity such as p. 99 of the Official Guidelines for Coding and Reporting would be helpful: “Do not assign BMI codes during pregnancy.”  Also, GCS is one of the measures in the SOFA score, which is another negative impact of this revision.

UPDATE: Per Coding Clinic, fourth quarter 2021, p. 112,  coma scale codes are to be used only in conjunction with traumatic brain injuries (TBI).

Recommendation: E-mail to communicate these issues that may have been overlooked when this revision was created to alleviate coder confusion.  

Updated 5/2022

Originally posted 2/26/2021

UPDATED: Diabetes mellitus, uncontrolled

Coding guidance prohibits the presumption or assumption of hyperglycemia versus hypoglycemia from the lab result, which is causing an increase in queries to the provider(s).

The ACDIS Pocket Guide includes criteria for each condition.  

The index leads to hyperglycemia with “poorly controlled” or “out of controlled." Lab orders at some facilities are rejected when only “uncontrolled” DM is documented. 

The need is a default code for “uncontrolled” to alleviate the need for and the increase in queries.   

Recommendation: The Regulatory Committee would like to begin working on a proposal to allow glucose/blood sugar lab findings to support code assignment.  

Please complete this four-question ACDIS survey on this topic to contribute and provide insight on how your facility or organization is handling code assignment and querying guidelines. 

Your answers will help the Regulatory Committee with decisions on a proposal.  

Updated 5/17/2022

Originally posted 2/28/2022

Incidental pregnancy

Official Guidelines for Coding and Reporting, 1.C.15.a.1: Should the provider document that the pregnancy is incidental to the encounter, then code Z33.1 (Pregnant state, incidental), should be used in place of any chapter 15 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.

Official Guidelines for Coding and Reporting, 1.C.21.c.3:  Z33.1 (Pregnant state, incidental).  This code is a secondary code only for use when the pregnancy is in no way complicating the reason for visit. Otherwise, a code from the obstetric chapter is required.

These guidelines appear to conflict. Pregnancy is rarely documented as “incidental” when the reason for admission and focus of treatment are for another reason. 

For example, when an admission is to treat and focus on major trauma and an early pregnancy gestational sac was discovered on ultrasound during trauma work up, it’s unclear if an OB code should be the principal diagnosis (PDX) because it’s not specifically noted as not complicating the pregnancy versus coding the most severe trauma as PDX with Z33.1 as a secondary code because the entire focus was on resolving life-threatening conditions and the pregnancy in no way had impact on the course of treatment.  

August 2022
Surgical complications

Coding Clinic, second quarter 2021, pp. 11-12:  Although after query the provider indicated the serosal tear was unavoidable, it was clinically significant, as it required further excision, complicating the surgery. Therefore, the excision of the small intestine is coded. Assign the following procedure code:

Coding Clinic, first quarter 2022, pp. 50-51: Although the surgeon stated that the serosal tear was unavoidable, it does not mean that the tear is not a surgical complication. For example, a serosal tear can range from a small nick requiring no treatment at all, to a major tear requiring removal of a portion of the small intestine. Serosal tears alone do not qualify as reportable diagnoses. If, however, the degree of a serosal tear alters the course of the surgery as supported by the medical record documentation, then the tear should be reported.


Coding Guidelines I.B.16 FY 2023:  There must be a cause-and-effect relationship between the care provided and the condition, and the documentation must support that the condition is clinically significant. It is not necessary for the provider to explicitly document the term “complication.” For example, if the condition alters the course of the surgery as documented in the operative report, then it would be appropriate to report a complication code. Query the provider for clarification if the documentation is not clear as to the relationship between the condition and the care or procedure.

It remains unclear what is to be considered clinically significant or what alters the course of surgery. Queries may not be helpful as the 2021 Coding Clinic discounts the query reply and explains the rationale for clinical significance (excision of intestine). If excision wasn’t necessary, but other procedures were (i.e. repair of tears, etc.), it’s unclear if this would be considered clinically significant and/or a surgical course alteration.  August 2022

​2021 hot topic list

Topic Summary Discussion point Date posted

Per Coding Clinic, November-December 1985, p. 15, pseudoseizure refers to a hysterical seizure and is coded as 300.11, Conversion disorder. 

Coding Clinic, first quarter 2021, p. 3, instructs code R56.9, Unspecified convulsions, if pseudoseizure documentation does not include "conversion disorder."

Although pseudoseizure was included in the ICD-9-CM code book index, it is not listed in the ICD-10-CM index. Be aware of the updated information with potential severity of illness (SOI) impact. 4/16/2021
Rib fracture due to CPR

Per Coding Clinic, first quarter 2013, p. 15, fractures of the rib occurring secondary to cardiopulmonary resuscitation (CPR) efforts are not classified as a complication because they are a known risk of this procedure.

Per Coding Clinic, first quarter 2021, p. 5, assign code M96.89, Other intraoperative and post procedural complications and disorders of the musculoskeletal system, as fractures of the rib are a known risk of this procedure.

Be aware of the updated information 4/16/2021
Postoperative sepsis

The tabular index states: 

T81.44:  Sepsis following a procedure

Use additional code to identify the sepsis.

A41:  Other sepsis

Code first postprocedural sepsis (T81.4-)

The Official Guidelines for Coding and Reporting, p. 25 states: For infections following a procedure, a code from T81.40, to T81.43 Infection following a procedure, or a code from O86.00 to O86.03, Infection of obstetric surgical wound, that identifies the site of the infection should be coded first, if known. Assign an additional code for sepsis following a procedure (T81.44) or sepsis following an obstetrical procedure (O86.04). Use an additional code to identify the infectious agent."

Discuss whether or not it is correct to follow the instructional note below as written and assign A41.9 (sepsis, unspecified organism) with T81.44 (Sepsis following a procedure). 

A41.9 is not excluded from the use additional note but does not identify an infectious agent or add specificity to the already identified sepsis as seen in T81.44. The use additional note may need revision to identify the “type” of sepsis (as is seen in the note under O99.21).

Consider requesting clarification:



Coding complications

Recent Coding Clinic advice seems to ask coders to contradict specific physician documentation when a complication of a procedure is documented as “expected.” Such reporting of complications may impact regulatory-based quality measures. 

Example: American Hospital Association (AHA) COVID-19 FAQ #54 says to assign complication codes for barotrauma from mechanical ventilation even though COVID weakened the alveoli making them overinflate.  

Question: The patient is diagnosed with acute COVID-19 viral infection with bilateral pneumonia and adult respiratory distress syndrome (ARDS) resulting in acute hypoxic and hypercapnic respiratory failure. The provider documented that the patient developed acute right-sided hydropneumothorax, likely due to barotrauma due to mechanical ventilation. Since the patient had COVID-19 pneumonia, which can weaken the lungs, would this affect code assignment? How should this case be coded?  

AnswerAssign code U07.1, COVID-19, as the principal or first-listed diagnosis, because the pneumonia is an acute manifestation of the COVID-19 infection. Assign code J12.82, Pneumonia due to coronavirus disease 2019, and code J80, Acute respiratory distress syndrome, as additional diagnoses for the pneumonia and ARDS. In addition, assign codes J95.859, Other complication of respirator [ventilator], J95.811, Postprocedural pneumothorax, and J94.8, Other specified pleural conditions, to capture hydropneumothorax barotrauma due to mechanical ventilation. The presence of COVID-19 does not affect code assignment of hydropneumothorax barotrauma. 

Continue to query the provider whether the condition is a complication when documentation is ambiguous or not explicitly stated as a complication or relation to preexisting condition or other etiology.  

Consider requesting clarification:  



Emphysema with COPD exacerbation

Per Coding Clinic, first quarter 2019, pp. 34-35, J43.9, Emphysema, unspecified, is to be assigned for a patient admitted for COPD exacerbation (J44.1) who also has emphysema.

J43.9 does not capture the acuity of the condition needing admission.  When assigned as a secondary code, it is not a CC and does not potentially impact the severity of illness as J44.1 may.

Consider proposing that the National Center for Health Statistics create a code for emphysema exacerbation and that CMS designate the new code as a CC.





2020 hot topic list

Topic Summary Discussion point Date posted
Comparative/ contrasting secondary conditions

The 1998 Coding Clinic instructs not to code comparative/contrasting secondary conditions as this guideline “is only for the selection of the principal diagnosis.” The 2016 Coding Clinic instructs to code these conditions if noted at the time of discharge. The current 2020 Official Guidelines for Coding and Reporting still only include specific comparative or contrasting instruction in Section II, Selection of Principal Diagnosis. Section III.C instructs to code uncertain diagnoses when documented at the time of discharge. 

Establish if both guidelines refer to all diagnoses (principal and secondary), making it appropriate to code all uncertain conditions documented at the time of discharge (the latest documentation in the stay).

Pancytopenia with febrile neutropenia A 2014 Coding Clinic says that "NCHS has agreed to address the issue of the excludes1 at category D61 at a future ICD-10-CM Coordination and Maintenance Committee (C&M) meeting". No further Coding Clinic has addressed this topic. However, the ICD-10 Official Guidelines for Coding and Reporting were published in 2015 with an Excludes 1 note exception that still stands today: “An exception to the Excludes 1 definition is the circumstance when the two conditions are unrelated to each other.” 

Determine in what circumstances queries will be generated to clarify if these conditions have separate etiologies and therefore would be appropriate to code separately. Educate using this documentation tip if needed.

Resolution: See Coding Clinic, third quarter 2020. Excludes 1 to be revised to Excludes 2. Under D61 for D70. Effective for discharges beginning October 1, 2020.


Arteriovenous malformation (AVM)

The ICD-9 and ICD-10 indexes have led/lead to a congenital nature but Coding Clinic, third quarter 2018, p. 21, instructs to code as acquired based on research. Establish at what point in time the hierarchy rule will be followed if the index and/or guideline has not been updated. 5/1/2020
Gangrene in diabetes 

I96 (gangrene, not elsewhere classified [NEC]) has an Excludes 2 note: Gangrene in diabetes (E08-E13 with .52).

There is a sub-term in the Alphabetic Index of ICD-10 under “gangrene” that states “gangrene>with diabetes.” It instructs the coder to “see diabetes, gangrene.” Based on The Official Guidelines for Coding and Reporting, the coder needs to code to the greatest level of specificity, so the coder is not able to stop at I96 but rather needs to go to the specified sub-term. When going to diabetes>gangrene as the Index instructs, the coder gets E11.52. There are no instructions under E11.52 stating to use an additional code for the gangrene.

ICD-10-CM Guideline I.B.9 states to “Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis.” In this case, the E11.52 clearly identifies all diagnoses present.

ICD-10-CM Guideline I.A.12.b states, “When an Excludes 2 note appears under a code, it is acceptable to use both the code and the excluded code together, 'when appropriate.' "

Establish when coding I96 (CC) (gangrene, NEC) with E11.52 (type II diabetes mellitus with gangrene) would be appropriate. If unsure, pose the question to the American Hospital Association (free of charge) at: 6/15/2020
Congenital conditions ICD-10-CM Official Guidelines for Coding and Reporting, I.C.17 states “Whenever the condition is diagnosed by the provider, it is appropriate to assign a code from codes Q00-Q99.” Some assume that reportable criteria is required (as stated in Guideline III), while others interpret this to mean that anytime a congenital condition is documented (and not completely corrected with past surgery), it should be coded. 

(Refer to the American Hospital Association's (AHA) Coding Clinic, first quarter 2013, p. 14: Sacral nevus on a newborn)

To avoid inconsistent data and the risk of denials, request that the National Center for Health Statistics revise Guideline I.C.17 to clarify that it is an exception to Section III. A possible clarification suggestion is:  Whenever the condition is diagnosed by the provider, it is appropriate to assign a code from codes Q00-Q99, regardless of the absence of reportable criteria or patient age.  

Requests may be e-mailed to:

Questions/comments may also be sent to CMS:

Intestinal Malabsorption with Severe Malnutrition 

Section notes for E40-E46 in the Tabular List include an Excludes 1 note for K90. 

Coding Clinic, fourth quarter 2017, pp. 108-109, instructs to assign both K90.9 and E43 for the question that was posed with a plan for others to consider revising the Excludes 1 note. 

Both Coding Clinic, fourth quarter 2019, pp. 65-66, and the Official Guidelines for Coding and Reporting, 2020 state that the instruction in the Tabular List takes precedence over the Guidelines and Coding Clinic

Coding guideline I.A. 12.a:  An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other.

When these conditions are related, E43 is not supported as a separate code. Request an update of the 2017 Coding Clinic at: 8/25/2020
Sepsis with organ dysfunction There have been no changes for this topic in the 2021 Alphabetic Index and Official Coding Guidelines (OCG). The 2021 OCG states that: “The instructions and conventions of the classification take precedence over guidelines”. Pages 11-12 instruct how to code conditions linked by “with.” Coding Clinic, fourth quarter 2019, pp. 65-66, discusses the hierarchy of conventions. Coding Clinic, fourth quarter 2017, pp. 99-100, includes “clarification of severe sepsis guideline.” There is risk that some may follow the index (with hierarchy in mind) and others may follow the OCG and Coding Clinic. It may be beneficial to request that the Cooperating Parties align all official coding resources to ensure that all are applied consistently. 9/23/2020
Right middle cerebral artery infarction and bilateral carotid artery occlusion  

Coding Clinic, third quarter 2020, pp. 28-29, instructs to code I63.231, Cerebral infarction due to unspecified occlusion or stenosis of right carotid artery, for documenation of stenotic plaque in the right carotid artery causing acute right MCA infarction. 

There is uncertainty by many as to whether I63.511, Infarction due to occlusion or stenosis of right MCA, was intentionally or unintentionally omitted or not. 

ICD-10-CM Official Guidelines for Coding and Reporting, p. 15, says: "When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code."

Consider query generation to clarify if occlusion/stenosis was present at both carotid and MCA sites. 

Consider also requesting follow-up clarification from the American Hospital Association (free of charge) at

Alcohol pancreatitis and alcohol dependence

Coding Clinic, first quarter 2020, p. 9, states that acute alcoholic pancreatitis due to alcohol dependence is not classified as an alcoholic induced disorder. 

In addition to assigning K85.20, Alcohol induced acute pancreatitis without necrosis or infection, it is advised to assign F10.20, Alcohol dependence, uncomplicated, rather than code F10.288, Alcohol dependence with other alcohol-induced disorder.

This advice appears to conflict with Coding Clinic, third quarter 2019, p. 8, which advises to assign an alcohol-induced disorder (F10.-) with G62.1, alcoholic polyneuropathy.

Consider requesting follow-up clarification from the American Hospital Association (free of charge) at 11/12/2020
Diverticulitis with peritonitis, large intestine

Code book index: Peritonitis > with diverticular disease > large intestine leads to K57.20, Diverticulitis of large intestine with perforation and abscess without bleeding.

Tabular index: There is no further code instruction pertaining to peritonitis under K57.2 or K57.20. 

Be aware of the note under the K57 category heading:

  • Code also if applicable peritonitis K65.-