Updated on: November 28, 2016

Watch for Hidden Changes to 2016 CM Guidelines

By Brad Ericson, MPC, CPC, COSC
Original story posted on: October 12, 2015

Astute coders comparing this year’s ICD-10-CM guidelines with those in their 2015 books might be surprised by several changes. 

Unmarked and made with no fanfare, the changes are worth noting.  

A recent line-by-line comparison by AAPC ICD-10 education staff verified changes mostly in Section I. They include the addition and changing of 7th characters and occurrence codes.

CMS maintains the changes were identified in reposted 2015 CM guidelines, but 2015 guidelines were pulled off the federal agency’s website this month. Guidelines downloaded by codebook publishers in 3rd quarter 2014 for use in their 2015 publications don’t indicate changes. Most ICD-10-CM books were to press by August. PCS guidelines anticipating the addition of new codes for 2016 were changed and reposted once a decision was made earlier this year.

Carefully read the guidelines for 2016 and you’ll find additional examples of sequela in 1.B.10; an incorrect code description in 1.C5.c; new examples for character A I 1.C13.c; changed examples and a new paragraph in 1.C19.a; clarification of malunion and nonunion I s1.C19.c.1; and additional paragraph in 1.C20.a.2. Occurrence codes are better explained in 1.C20.b and 1.C20.d, while an additional exclusion can be found in 1.d.21.16.  Section II.E has been deleted. 

Guideline Location



Section 1.10

Sequela description added

Examples of sequela include: scar tissue after a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis.

Section 1.C.5.c

Deleted wording

“and post procedural septic shock”
“T81.4 or O86.0 should be coded first followed by code R65.21. Severe sepsis without septic shock”.

Section 1.C.5.c

Paragraph added for Sepsis due to Post procedural infection

“If a post procedural infection has resulted in post procedural septic shock, the code for the precipitating complication, such as code T81.4, Infection following a procedure, or O86.0, Infection of obstetrical wound should be coded first followed by code T81.12- Postprocedural septic shock. A code for systemic infection should also be coded. “

Section 1.C.13.c

Rewording of the 7th characters

“evaluation and continuing treatment by the same or different physician”. While the patient is seen by a new or different provider over the course of the treatment for a pathologic fracture, assignment of the 7th character is based on whether the patient is undergoing active treatment or not whether the provider is seeing the patient for the first time”.

Section 1.C.19.a

Rewording for 7th character

“While the patient may be seen by a new or different provider over the course of the treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time. (first paragraph)


Added paragraph

“For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem. For example, Code T84.50XA, Infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter, is used when active treatment is provided for the infection, even though the condition relates to the prosthetic device , implant, or graft that was placed at a previous encounter”


Rewording of A

“Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or different physician.”


Rewording of D

“cast change or removal, an X-ray to check healing of a fracture, Removal or external or internal fixation device, medication adjustment, other aftercare and follow-up visits following the treatment of the injury or condition.”

Section 1.C.19.c.1

Rewording of Initial

”evaluation and continuing (ongoing) treatment by the same or different physician"


Paragraph added

"Malunion/nonunion: The appropriate 7th character for Initial encounter should be assigned for a patient who delayed seeking treatment for the fracture or nonunion"

Section 1.C.20.a.2

Paragraph added

Most categories in Chapter 20 have a 7th character requirement for each applicable code. Most categories in this chapter have three 7th character values: A, Initial encounter, D, Subsequent encounter and S, Sequela. While the patient may be seen by a new or different provider over the course of treatment for an injury or condition, assignment of the 7th character for external cause should match the 7th character of the code assigned for the associated injury or condition for the encounter.

Section 1.C.20.b

POA rewording - 2nd paragraph

Generally, a place of occurrence is assigned only once, at the initial encounter for treatment. However, in the rare circumstance that a new injury occurs during hospitalization, an additional place of occurrence may be assigned. No 7th characters are used for Y92.

Section 1.C.20.d

Additional wording added

"However, in the rare instance that a new injury occurs during hospitalization, an additional place of occurrence code may be assigned.”


Exclusion added

Except: Z00.6 (this is not a primary Dx)

Section II.E

Guideline is deleted effective Oct 1, 2014

A symptom followed by contrasting/comparative diagnosis "when a symptom is followed by contrasting/comparative diagnoses, the symptom is sequenced first. However if the symptom is integral to the conditions listed, no code for the symptom is reported. All the contrasting/comparative diagnoses should be listed as additional diagnoses.”

While additional changes are not expected to ICD-10-CM immediately, the health care community will watch upcoming ICD-10 committee meetings closely for adjustments in the 2017 addition. Thawing of the frozen code set will no doubt calve notable changes.   

About the Author

Brad Ericson has written about healthcare for 35 years. He is a credentialed member of AAPC, where he is director of publishing. Prior to that, he wrote and edited at Optum, Medicode/St. Anthony, and Aetna.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.

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