In conjunction with the updated International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code set, the ICD-10-CM Official Guidelines for Coding and Reporting FY 2022 have been published and are effective for dates of service on and after October 1, 2021. Highlights of the changes to the guidelines are listed in this article by topic.

Code assignment is based on documentation by the physician or other qualified health care professional (QHP) legally accountable for establishing the patient’s diagnosis, with few exceptions. Documentation by another clinician (eg, nurse, medical assistant, social worker) is sufficient to support reporting codes for the items on the following list when the associated diagnosis (eg, overweight, obesity, acute stroke, pressure ulcer, a condition classifiable to category F10 [alcohol-related disorders]) has been documented by the patient’s physician or QHP.

Patient documentation may be used to assign codes for SDOH as long as the information...

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