Implementation of New Diagnosis Codes: Irritant Contact Dermatitis in 2022 and Factors Influencing Care in 2023

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In August 2021, this author announced the creation of new diagnosis codes for irritant contact dermatitis that became effective on October 1, 2021. I want to take this opportunity to commend the excellent collaboration between 3M, the Wound, Ostomy, and Continence Nurses Society™ (WOCN Society), and me: we worked together to apply for and receive 8 new ICD-10-CM codes for moisture-associated skin damage (MASD). As you know, another term for these conditions is irritant contact dermatitis.  

For the past 1½ years this author consulted with 3 members of the WOCN Society to create the application for the new diagnosis codes. The members were: Mikel Gray, PhD, RN, FNP, CCCN, FAANP, FAAN; Donna Bliss, PhD, RN, FGSA, FAAN; and Laurie McNichol, MSN, RN, CNS, GNP, CWOCN, CWON-AP, FAAN, WOCN. The team was formed in October of 2020 with the goal of obtaining additional specific codes for irritant contact dermatitis that is due to various body fluids.

At the time, the only available diagnosis code was for Irritant contact dermatitis (ICD 10-CM Code L24) caused by a variety of potentially irritating substances to the skin such as detergents, oils, greases, solvents, drugs, plants, and metals. The L24 code did not cover the most clinically relevant and prevalent forms of irritant contact dermatitis caused by body fluids: incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), peristomal MASD, and peri wound MASD. When these conditions were documented in the medical record, the wound/ulcer management professionals only had the choice of inappropriate, non-specific, or miscellaneous diagnosis codes to report MASD conditions. Using the nonspecific codes did not accurately describe the presence, management, and outcomes of these specific conditions.

How the Team Created the Codes

In case you are wondering just how much work is required to apply for new ICD-10-CM codes, following is an overview of the work that was performed:

Because many terms are used by wound/ulcer management professionals to describe these conditions, the team wanted to create uniform definitions of the conditions in addition to creating new diagnosis codes. The team gathered information to demonstrate that the existing code was not adequate and that new codes were necessary. That information was inserted into the ICD-10-CM application for the new codes:
·               Existing ICD-10-CM code for the condition, with a notation that specific diagnosis codes were not available for irritant contact dermatitis due to body fluids.
·               A description by the WOCN Society about the need to collect information pertaining to the conditions which lacked specific codes. 
·               Explanation that these conditions are on the rise in elderly populations and have created a need to track and report these conditions for incidence and research.
·               A thorough literature summary and bibliography, created by the clinical professionals in the group, which included pictures and descriptions of the different types of conditions.
 
Then the group assembled and submitted the total application (including proposed new ICD-10-CM codes, needs assessment for unique codes, literature review and summary, and bibliography) by December 4, 2020. Mikel Gray presented the original proposal at the March 17–18, 2020, Coordination and Maintenance Committee Meeting, specifically the National Center for Health Statistics (NCHS), which is responsible for the ICD-10-CM diagnosis codes used in the United States. Finally, the WOCN Society workgroup responded to the questions about the proposal from the March meeting that were received by the committee and the public. The responses to the inquiries were accepted and no further comments were received. The revised proposal was approved at the September 2021 meeting without objection.
 
The new codes went into effect on October 1, 2021, and they were published in the “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2022 Rates.”

A Closer Look at the New Codes

Four of the new codes are listed under the subcategory:
 
L24.A Irritant contact dermatitis due to friction or contact with body fluids
   Excludes 1: irritant contact dermatitis related to stoma or fistula (L24.B-)    
   Excludes 2: erythema intertrigo (L30.4)
L24.A0 Irritant contact dermatitis due to friction or contact with body fluids, unspecified
L24.A1 Irritant contact dermatitis due to saliva
L24.A2 Irritant contact dermatitis due to fecal, urinary or dual incontinence
   Excludes 1: diaper dermatitis (L22)
L24.A9 Irritant contact dermatitis due friction or contact with other specified body fluids
             Irritant contact dermatitis related to endotracheal tube
             Wound fluids, exudate

Four more new codes are under the subcategory:

L24.B. Irritant contact dermatitis related to stoma or fistula
   Use Additional Code to identify any artificial opening status (Z93.-), if applicable, for contact dermatitis related to stoma or secretions
L24.B0 Irritant contact dermatitis related to unspecified stoma or fistula
             Irritant contact dermatitis related to stoma NOS
             Irritant contact dermatitis related to stoma NOS
L24.B1 Irritant contact dermatitis related to digestive stoma or fistula
             Irritant contact dermatitis related to gastrostomy
             Irritant contact dermatitis related to jejunostomy
             Irritant contact dermatitis related to saliva or spit fistula
L24.B2 Irritant contact dermatitis related to respiratory stoma or fistula
             Irritant contact dermatitis related to tracheostomy
L24.B3 Irritant contact dermatitis related to fecal or urinary stoma or fistula
             Irritant contact dermatitis related to colostomy
             Irritant contact dermatitis related to enterocutaneous fistula
             Irritant contact dermatitis related to ileostomy

As previously mentioned, the diagnosis code L30.4 Erythema intertrigo was already listed under subcategory L30 Other and unspecified dermatitis.

Effective October 1, 2021, wound/ulcer management professionals should have incorporated the new specific irritant contact dermatitis terminology into their clinical assessments, their documentation, and their coding. They should have started by assessing the relevant terminology that they used prior to the new diagnosis codes. Then, they should have oriented their team to the new codes and definitions. The clinical staff should have updated their documentation of these conditions to align with the new code descriptions, regardless of written or electronic documentation. If using an electronic health record (EHR), it should have been updated with the new irritant contact dermatitis codes. The coders should have been educated about the new codes and the refined documentation. In addition, the coding systems, and the charging systems should have been updated by their vendors. These updates will allow the coders to capture the information regarding MASD that was unavailable prior to 2022.
 
The best way to determine the appropriate code is by determining the type of body fluid that is causing the irritant contact dermatitis. For example, fistula of XXXXX. The code will be assigned not by the fistula but the type of body fluid that is causing the irritation.
 
Because much effort by the WOCN Society was expended to create these new codes, wound/ulcer management stakeholders should use the codes in their documentation and coding to report irritant contact dermatitis occurring in the aging population. Please ensure that all providers of wound/ulcer management in your facility are aware of the new codes and encourage them to appropriately document the conditions so the coders can easily identify the various types of irritant contact dermatitis in the medical record. This author recommends that you conduct a claims audit, on at least 3 months of claims, to ensure that the coders are capturing the new diagnosis codes that are documented in the medical record.

Factors Influencing Care Codes

The Inpatient Prospective Payment System (IPPS) Proposed 2023 Rule is here. The tables that contain all of the new ICD-10-CM/PCS codes appear here. The tables are as follows:
 
Table 6A—New Diagnosis Codes; Table 6B—New Procedure Codes; Table 6C-Invalid Diagnosis Codes; Table 6E-Revised Diagnosis Code Titles; Table 6G.1—Proposed Secondary Diagnosis Order Additions to the CC Exclusions List; Table 6G.2—Proposed Principal Diagnosis Order Additions to the CC Exclusions List; Table 6H.1—Proposed Secondary Diagnosis Order Deletions to the CC Exclusions List; Table 6H.2—Proposed Principal Diagnosis Order Deletions to the CC Exclusions List; Table 6I.1—Proposed Additions to the MCC List; Table 6I.2—Proposed Deletions to the MCC List; Table 6J.1—Proposed Additions to the CC List; and Table 6J.2—Proposed Deletions to the CC list.
 
Please review these tables with your team prior to October 1, 2022. This year there are not a lot of wound specific codes that were added to the system. However, Table 1 shows the additions to the Z code listings. If you recall, Z codes are other factors influencing care. The table includes a few new codes that may be pertinent to wound/ulcer management. You will see that these codes represent long term use of drug/biologics, immunosuppressants as well as patient/caregiver non-compliance issues. Many of these codes may assist you in documenting the medical necessity of treatment in certain individuals as well as the complexity of certain patients undergoing wound/ulcer management. Please review these with your staff.

Donna Cartwright is senior director of health policy and reimbursement at Integra LifeSciences Corp., Plainsboro, NJ. She is an AHIMA-approved ICD-10-CM/PCS trainer, and she has been designated as a fellow of the American Health Information Management Association.

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