New ICD-10-CM/PCS Codes Become Effective April 1

The Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) is implementing three new diagnosis codes into ICD-10-CM, effective April 1, 2022. The Centers for Medicare & Medicaid Services (CMS) is implementing nine new procedure codes to describe the introduction or infusion of therapeutics, including vaccines for COVID-19 treatment, into ICD-10-PCS, also effective April 1, 2022.

New ICD-10-CM Codes

Two new ICD-10-CM codes have been created for underimmunization for COVID-19 status:

• Z28.310   Unvaccinated for COVID-19
• Z28.311   Partially vaccinated for COVID-19

A third new code describes other underimmunization status:

• Z28.39   Other underimmunization status

Additional codes are assigned, if applicable, to provide additional reasons for underimmunization, such as contraindication (Z28.0-) or the patient’s decision for reasons of belief or group pressure (Z28.1).

The new code for “other underimmunization status” includes delinquent immunization status and lapsed immunization schedule status.

The new codes for underimmunization for COVID-19 status should not be assigned for individuals who are not eligible for the COVID-19 vaccines (e.g., children under age 5).

The ICD-10-CM Official Guidelines for Coding and Reporting have been updated to provide guidance regarding the use of the new ICD-10-CM codes. Code Z28.310, Unvaccinated for COVID-19, may be assigned when the patient has not received at least one dose of any COVID-19 vaccine. Code Z28.311, Partially vaccinated for COVID-19, may be assigned when the patient has received at least one dose of a multi-dose COVID-19 vaccine regimen but has not received the full set of doses necessary to meet the CDC’s definition of “fully vaccinated” in place at the time of the encounter.

New ICD-10-PCS Codes

Three new ICD-10-PCS codes have been created for the administration of fostamatinib (Tavalisse^®):

• XW0DXR7    Introduction of fostamatinib into mouth and pharynx, external approach, new technology group 7
• XW0G7R7     Introduction of fostamatinib into upper GI, via natural or artificial opening, new technology group 7
• XW0H7R7     Introduction of fostamatinib into lower GI, via natural or artificial opening, new technology group 7

Fostamatinib is approved as a treatment for adult chronic immune thrombocytopenia. A request for emergency use authorization (EUA) for fostamatinib is under review by the US Food and Drug Administration (FDA) for the treatment of hospitalized adult COVID-19 patients. Fostamatinib is a spleen tyrosine kinase (SYK) inhibitor. SYK is involved in the intracellular signaling pathways of many different immune cells.

One new code has been created for the administration of tixagevimab and cilgavimab monoclonal antibody (Evusheld™):

• XW023X7      Introduction of tixagevimab and cilgavimab monoclonal antibody into muscle, percutaneous approach, new technology group 7

The FDA granted Evusheld EUA for the pre-exposure prophylaxis of COVID-19 in adults and pediatric individuals who are not currently infected with SARS-CoV-2 and who have not experienced a known recent exposure to an individual infected with SARS-CoV-2 and

• who have moderate to severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments and may not mount an adequate immune response to COVID-19 vaccination, or
• for whom vaccination with any available COVID-19 vaccine, according to the approved or authorized schedule, is not recommended due to a history of severe adverse reaction (e.g., severe allergic reaction) to a COVID-19 vaccine(s) and/or COVID-19 vaccine component(s).

One new code has been created for other new monoclonal antibody COVID-19 treatments that are administered intramuscularly that may become available and do not yet have a unique code.  This new ICD-10-PCS code is:

• XW023Y7      Introduction of other new technology monoclonal antibody into muscle, percutaneous approach, new technology group 7

Four new ICD-10-PCS procedure codes have been created for COVID-19 vaccines. Two of the new codes were created for vaccines described as a third dose, and two codes were created for vaccines described as boosters. A COVID-19 vaccine booster shot is an additional dose of a vaccine given after the protection provided by the original shot(s) has begun to decrease over time. Currently, the CDC recommends booster doses for individuals age 12 and older after getting two doses of an mRNA COVID-19 vaccine (Pfizer-BioNTech or Moderna vaccine) or one dose of Johnson & Johnson’s Janssen COVID-19 vaccine.

A COVID-19 third dose refers to an additional vaccine dose administered to people with moderately or severely compromised immune systems. This additional dose is intended to improve immunocompromised people’s response to their initial vaccine series. The CDC currently recommends that individuals ages 12 years and older who are moderately or severely immunocompromised receive a primary series of three doses of an mRNA COVID-19 vaccine, plus one booster of an mRNA COVID-19 vaccine. Children ages 5 through 11 years who are moderately or severely immunocompromised should receive a primary series of three doses of the Pfizer-BioNTech COVID-19 vaccine. A booster is not recommended for this age group at this time. Individuals ages 18 years and older who are moderately or severely immunocompromised and received the one-dose J&J/Janssen COVID-19 vaccine should get a second dose of either Pfizer-BioNTech or Moderna COVID-19 vaccine (mRNA COVID-19 vaccines) as well as a booster.

Please see the CDC website for the most up-to-date COVID-19 vaccination recommendations as the guidance may change over time.

The four new vaccine codes are:

• XW013V7      Introduction of COVID-19 vaccine dose 3 into subcutaneous tissue, percutaneous approach, new technology group 7
• XW013W7     Introduction of COVID-19 vaccine booster into subcutaneous tissue, percutaneous approach, new technology group 7
• XW023V7      Introduction of COVID-19 vaccine dose 3 into muscle, percutaneous approach, new technology group 7
• XW023W7     Introduction of COVID-19 vaccine booster into muscle, percutaneous approach, new technology group 7

CMS noted in its announcement of the new COVID-19 vaccine codes that for hospitalized patients, Medicare pays for the COVID-19 vaccines and their administration separately from the diagnosis-related group (DRG) rate. As such, Medicare expects that the appropriate CPT codes will be used when a Medicare beneficiary is administered a vaccine while a hospital inpatient.

See the CMS website for additional information about the new ICD-10-PCS codes going into effect on April 1, 2022.

See the NCHS website for the updated ICD-10-CM Official Guidelines for Coding and Reporting and additional information about the new ICD-10-CM codes becoming effective on April 1, 2022.

Sue Bowman (sue.bowman@ahima.org) is a senior director of coding policy and compliance at AHIMA.