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Health in Context: Understanding the Impact of Social Determinants of Health (SDoH)
Summary of a Presentation by Rachel Mack, MSN, RN, CCDS, CDIP, CCS, CRC at the 2025 CHIMA Annual Meeting
In this must-read article, you will:
Uncover how Social Determinants of Health (SDoH) like housing, food access, and education drive health outcomes beyond clinical care.
Reveal the real-world effects of SDoH on chronic illness, health disparities, and population-level risks.
Demystify the power of ICD-10-CM Z codes in capturing and addressing social needs in medical records.
Break down the nine Z code categories that illuminate a patient’s lived experience and care barriers.
Tackle the documentation challenges and discover innovative solutions that support equitable, data-informed care.
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“I have worked with UASI for many years, they are my go to for CDI. UASI provides experienced CDI staffing resources as well great products with their CDI assessment and their customizable CDI audits. Partnering with UASI is helping our CDI team continuously grow and improve.”
- Tallahassee Memorial Healthcare
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Discover a comprehensive range of healthcare solutions designed to optimize revenue, enhance compliance, and improve operational efficiency. From coding and CDI to risk-based services and revenue integrity, UASI provides expert support to meet your unique needs.
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At UASI, we optimize your risk adjustment and value-based care initiatives with our specialized risk-based services, ensuring accurate coding and improved financial outcomes.
CDI SERVICES
UASI enhances the accuracy and completeness of your clinical documentation, ensuring compliance and optimal reimbursement through our expert CDI services.
DENIALS & REVENUE INTEGRITY
Maintain financial health and compliance with UASI's comprehensive revenue integrity services, including auditing, denials management, and process optimization.
Explore our INSIGHTS section for valuable resources, including articles, results, whitepapers, case studies, and more. Stay informed and gain expert knowledge to drive your healthcare organization's success with UASI.
Rural hospitals are lifelines for millions of Americans but face unique operational, financial, and regulatory challenges. At the 2025 AHIMA Conference, Leah Jeffries, RHIT, CDIP, CCS, CCS-P, Managing Consultant at UASI, will present “The Nuances and Complexity of the Revenue Cycle Management of Critical Access Hospitals.” This session explores how Critical Access Hospitals (CAHs), small rural facilities designated by CMS, operate under different rules than larger hospitals. With up to 25 inpatient beds, distinct Conditions of Participation, and cost-based reimbursement, CAHs must balance strict requirements with financial stability while serving underserved communities. Key Takeaways Learn the history, purpose, and eligibility criteria of CAHs, including cost-based reimbursement and flexible billing options. Understand how Conditions of Participation differ from acute-care hospitals, covering bylaws, quality programs, infection control, and documentation standards. Explore cost-based reimbursement for inpatient, outpatient, and swing-bed services plus Method I and II billing for professional services. Discover common coding pitfalls unique to CAHs, from swing-bed and ambulance coding to anesthesia modifiers and charge validation. Gain strategies to improve documentation, reduce denials, and strengthen compliance despite limited resources. Looking Ahead There will also be a review recent and upcoming regulatory changes shaping rural healthcare. With over 140 rural hospitals having closed since 2005, attendees will leave equipped to protect reimbursement, improve revenue cycle processes, and sustain access to care. Critical Access Hospitals are more than healthcare providers; they are anchors for rural economies. This session offers actionable strategies to help CAHs thrive despite unique challenges. If you work in revenue cycle management, health information management, compliance, or clinical documentation, this is a must-attend session at AHIMA 2025. Sources: National Center for Biotechnology Information. (n.d.). Figure 22, Distribution of critical access hospitals in the United States, 2022. In 2022 National Healthcare Quality and Disparities Report. NCBI Bookshelf. U.S. Department of Agriculture, Economic Research Service. (n.d.). 146 rural hospitals closed or stopped providing inpatient services from 2005 to 2023 in the United States. ERS Charts of Note. Centers for Medicare & Medicaid Services. (n.d.). Critical Access Hospitals. Centers for Medicare & Medicaid Services. (n.d.). Medicare Claims Processing Manual, Chapter 2: Critical Access Hospitals (CMS Manual). Centers for Medicare & Medicaid Services. (n.d.). Critical Access Hospitals Center.
Summary of a Presentation by Rachel Mack, MSN, RN, CCDS, CDIP, CCS, CRC at the 2025 CHIMA Annual Meeting
UASI is proud to announce the appointment of Autumn Reiter as Chief Strategy and Solutions Officer. With 20 years of nursing experience, an MBA, and a decade of leadership in revenue cycle, payment integrity, and documentation improvement, Autumn brings a rare blend of clinical insight and strategic business expertise to the role. Autumn brings 20+ years of experience leading teams and delivering large scale solutions in CDI and Tech Enablement, Payment Integrity, and Provider Risk Strategies. Throughout her career, she has led large-scale programmatic builds, developed innovative solutions to optimize revenue capture, and implemented operational efficiencies that improved compliance and reduced costs for healthcare organizations nationwide. “UASI’s reputation for delivering exceptional results through strategic mid-revenue cycle solutions is unmatched in the industry,” said Reiter. “I am excited to join a team that shares my passion for bridging clinical care and business operations to drive quality, compliance, and operational excellence in healthcare reimbursement.” The addition of Autumn Reiter reflects UASI’s ongoing commitment to expanding its leadership team with seasoned industry experts who are dedicated to helping clients strategically optimize their revenue cycle, streamline operations, and enhance patient care. About UASI For over 40 years, UASI has bridged the gap between people and processes in financial and clinical operations by providing solutions that reduce revenue leakage, enhance operational efficiency, and ensure quality and compliance.
Why CMS Star Ratings Matter More Than Ever Hospitals are constantly measured on their quality of care, but few metrics carry as much weight as the Centers for Medicare & Medicaid Services (CMS) Star Ratings. These ratings influence how patients choose hospitals, how payers negotiate contracts, and how organizations position themselves in an increasingly competitive healthcare landscape. The Role of Star Ratings The CMS Star Ratings program evaluates hospitals across a wide range of quality measures. These include clinical outcomes such as readmissions and mortality, safety indicators like hospital-acquired conditions, and patient experience surveys addressing communication, responsiveness, and cleanliness. Hospitals receive an overall score that is highly visible to the public and payers. Impact on Patient Choice and Public Perception Patients want assurance that the care they receive will be safe and effective. Star Ratings serve as a shorthand for quality, guiding patient choice when selecting where to receive treatment. Hospitals with higher ratings often enjoy stronger reputations in their communities, while lower ratings can raise concerns about safety and performance. Influence on Reimbursement and Contracts Star Ratings are not just symbolic. They affect how hospitals are reimbursed, influence payer negotiations, and may unlock incentive payments for high performance. For many organizations, Star Ratings directly shape financial sustainability and the ability to reinvest in staff and technology. The Hidden Impact of Denials on Star Ratings Denials are often seen as a revenue cycle issue, but their impact goes far beyond delayed payments. When denials distort clinical data, they also undermine a hospital’s performance in CMS Star Ratings. Financial Consequences Every denied claim represents lost or delayed revenue. This directly reduces the resources available for quality initiatives, staffing, and patient experience improvements. Hospitals under financial strain may struggle to invest in areas that strengthen Star Ratings. Data Accuracy and Risk Adjustment Denials linked to documentation gaps or coding errors can lead to underreporting of patient complexity. Missed severity of illness and comorbidities affect risk adjustment, making outcomes such as mortality or readmissions appear worse than they are. Inaccurate data paints an incomplete picture of care quality. Denials influence critical Star Ratings measures, including: Mortality rates Readmission rates Complications Patient safety indicators When denials obscure true performance, hospitals risk lower ratings despite providing high-quality care. Operational Burden Staff rework and appeals consume time that could otherwise be dedicated to patient care, CDI initiatives, and proactive quality improvements. This operational distraction further hampers performance on Star Ratings measures. Organizations that do not address denial management place both their financial health and their public reputation at risk. By taking a proactive and comprehensive approach to denial prevention and management, hospitals can improve patient outcomes, protect vital revenue streams, and reinforce the trust and confidence of their communities and stakeholders. Turning Denial Prevention into Star Ratings Success Reducing denials is about more than revenue recovery. It is a strategic opportunity to strengthen documentation, improve data accuracy, and ultimately elevate CMS Star Ratings. Key Risks to Address Hospitals that do not proactively manage denials face three major risks: Missed capture of severity of illness and risk adjustment Underreported quality outcomes Reduced ability to invest in staff, technology, and patient experience Strategic Priorities for Hospitals Strengthen Documentation and Coding Accuracy: Clear, complete provider documentation ensures accurate code assignment and proper reflection of patient complexity. Proactively Manage Denials and Appeals: Early intervention prevents errors from cascading into distorted data and reduced reimbursement. Align CDI, Coding, and Revenue Cycle with Quality Measures: Collaboration across these functions ensures accurate reporting of outcomes and supports better ratings. Reinforce the Cycle of Accuracy: Accurate documentation leads to improved reimbursement, which enables reinvestment in quality initiatives, ultimately driving higher Star Ratings Connecting Quality and Finance Denial prevention directly supports quality outcomes, enhances reimbursement, and improves patient trust. By managing denials strategically, hospitals turn a traditional operational challenge into an opportunity for growth and leadership in value-based care. Resources: Centers for Medicare & Medicaid Services. (2024). Overall hospital quality star rating. CMS. https://www.cms.gov/medicare/quality/hospital-star-ratings Centers for Medicare & Medicaid Services. (2025). Transforming Episode Accountability Model (TEAM). CMS. https://www.cms.gov/priorities/innovation/innovation-models/team-model Centers for Medicare & Medicaid Services. (2024). Hospital quality star ratings methodology. CMS. https://qualitynet.cms.gov/inpatient/measures/hospital-star-ratings American Hospital Association. (2025). Denials management in hospitals. AHA. https://www.aha.org/topics/denials-management Centers for Medicare & Medicaid Services. (2024). Meaningful Measures 2.0: Moving to measure alignment. CMS. https://www.cms.gov/meaningful-measures-20 American College of Surgeons. (2025). Preparing for TEAM: Transforming Episode Accountability Model
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HCC RISK ADJUSTMENT
V24 - V28
Are You Ready?
Ensuring your organization makes a successful transition
Learn about the changes and implications of the HCC model transition from V24 to V28, featuring industry experts in medical coding and CDI. We will discuss the changes and implications of the HCC model transition from V24 to V28 and gain actionable insights on navigating challenges, optimizing workflows, and ensuring accurate risk scoring under the new model.
Understanding that risk adjustment is not just HCC but is underlying in everything we do in mid revenue.
Download the Provider Queries 101 article to learn how better documentation practices can have a significant impact on your organization's bottom line.
Explore UASI's comprehensive resource page for valuable insights, tools, and expertise in healthcare staffing, revenue cycle management, and compliance solutions
CDI Tip: Capturing Firearm Injury Intent from Other Clinicians’ Documentation What’s New in FY 2026? CMS and ICD-10-CM guidelines now allow documentation by clinicians other than the patient’s provider (e.g., nurses, social workers, trauma team) to be used for assigning external cause codes, including firearm injury intent. This change supports more accurate public health reporting and injury surveillance Key Actions for CDI Specialists Review All Clinical Notes Check ED notes, nursing assessments, social work documentation, and EMS reports for statements about firearm injury intent (e.g., accidental, assault, self-harm, undetermined). Apply the New Intent Hierarchy If intent is clearly documented by any clinician, code accordingly: Accidental: W34 series Assault: X93–X95 series Self-harm: X72–X74 series Undetermined: Y22–Y24 series If no intent is documented, follow the updated guideline: default to undetermined intent for firearm injuries (Y24.9), unless otherwise specified. Query When Needed If conflicting documentation exists (e.g., ED note states “possible assault,” nursing note says “accidental”), query the provider for clarification. Document Source When coding based on another clinician’s note, ensure the documentation is clearly attributed in the record. Pro Tip: Incorporate firearm injury intent review into your trauma and ED CDI workflows. Educate providers that intent matters for coding, quality metrics, and injury prevention programs. Example Clinical Scenario with Query: Setting: ED, trauma bay Patient: 28-year-old male with a through and through gunshot wound of the left thigh; hemodynamically stable. Documentation in record: ED triage RN note: “Pt states he was shot by someone outside a bar.” EMS run sheet: “Bystanders report drive by shooting; single GSW to L thigh.” ED SW note: “Patient reports unknown assailant; denies self-harm.” ED provider note: “GSW L thigh; hemorrhage controlled; analgesia given.” Intent not specified in provider note or discharge summary Query: Documentation in the medical record shows that the patient was injured by a firearm. Please clarify the intent of the firearm injury for this encounter, based on your clinical judgment and the medical record. Assault (injury inflicted by another person) Accidental/unintentional Intentional self-harm Undetermined (unable to determine intent from available information) Other (please specify): _______________________
What is ventricular standstill? SA node is functioning, and P waves are present on EKG. There is no ventricular response, no contractions of the muscle. The presence of complete heart block with no escape rhythm. No cardiac output with the patient in full arrest. May be paroxysmal or prolonged.
What does it mean when “neurostorming” is documented? “Neuro storm” and other similar terms such as autonomic storms, hypothalamic dysregulation syndrome and sympathetic storms all equate to the condition paroxysmal sympathetic hyperactivity (PSH). This syndrome was formally named in 2014 by an international panel looking at preferred nomenclature, definition and diagnostic criteria. PSH is defined as a disorder in the regulation of autonomic function most observed in patients with acute brain injury, most notably severe traumatic brain injury. What are the risk factors for PSH? Traumatic brain injury (TBI) Hypoxic ischemic injury What are the clinical indicators of PSH? Sinus tachycardia Elevated systolic blood pressure Tachypnea associated with respiratory alkalosis Diaphoresis that can progress to dehydration Hyperthermia in some cases Severe cases may have dystonic posturing How is PSH treated? Reducing stimulation Managing hyperthermia and hyperventilation Medications IV Morphine Gabapentin Beta blockers Baclofen Precedex infusion Dantrolene Coding and CDI considerations for the documentation of “neurostorming” The ICD-10-CM condition code most appropriate for reporting of PSH is G90.89, Other disorders of autonomic nervous system. There is no specific code to identify neurostorm or PSH. There are also no instructional notes for the code G90.89. Per the ICD10-CM Official Coding Guidelines, “ If a main term cannot be located, consider a synonym, an eponym, or another alternative term. Once the main term is located, search for subterms, notes, or cross-references. Subterms provide many types of more specific information and must be checked carefully, following all the rules of alphabetization. The main term code entry should not be assigned until all subterm possibilities have been exhausted. During this process, it may be necessary to refer again to the medical record to determine whether any additional information is available to permit assignment of a more specific code. If a subterm cannot be located, the nonessential modifiers following the main term should be reviewed to see whether the subterm may be included there. If not, alternative terms should be considered” Current coding advice notes that when the index is confusing, leading to an inappropriate code, further research is needed when the title of the code suggested by the index clearly does not identify the condition correctly. Regarding the CDI professional, it is allowable to report code G90.89, Other disorders of autonomic nervous system in the instance where “neurostorm” is documented by the provider. A query would not be needed for clarification. References: American Hospital Association (AHA). ICD-10-CM Coding Clinic, Second Quarter 2025, p. 4. Available from: AHA Coding Clinic Centers for Medicare & Medicaid Services (CMS). (2025). ICD-10-CM Official Guidelines for Coding and Reporting. Available from: CMS ICD-10-CM Guidelines Rabinstein, A. (2024). Paroxysmal sympathetic hyperactivity. UpToDate. Available from: UpToDate – Paroxysmal sympathetic hyperactivity
Background: With the 2026 IPPS Proposed Final Rule comes a new diabetes code, E11.A, Type II diabetes mellitus without complications in remission. This is a non-CC/MCC and is assigned to MDC 10. ICD-10-CM Official Guidelines for Coding and Reporting 2026: Section I.C.4.a.1.(b) - “Code E11.A, Type 2 diabetes mellitus without complications in remission, is assigned based on provider documentation that the diabetes mellitus is in remission. If the documentation is unclear as to whether the Type 2 diabetes mellitus has achieved remission, the provider should be queried. For example, the term “resolved” is not synonymous with remission.” Clinical criteria for diabetes in remission: Note* - Remission does not mean cure. Ongoing monitoring is essential as relapse is possible. 1. Prior Diagnosis of Diabetes Mellitus Documented history of type 2 diabetes mellitus, diagnosed using standard criteria: HbA1c ≥ 6.5% Fasting plasma glucose ≥ 126 mg/dL 2-hour plasma glucose ≥ 200 mg/dL during an OGTT Random plasma glucose ≥ 200 mg/dL with classic symptoms 2. Normal or Controlled Glucose Levels Without Medications The patient is not taking any antidiabetic medications (oral agents, insulin, or non-insulin injectables). Glycemic control is sustained through lifestyle modifications, such as diet and exercise. HbA1c < 6.5%, and sometimes < 6.0%, on two occasions at least 6 months apart without pharmacologic therapy. 3. Duration of Remission Partial remission: HbA1c < 6.5% and fasting glucose 100–125 mg/dL for at least 1 year without medications. Complete remission: HbA1c in the normal range (<5.7%) and fasting glucose <100 mg/dL for at least 1 year. Prolonged remission: Complete remission lasting ≥5 years. 4. Documentation Must Include Clear statement that diabetes is in remission or resolution. No current use of diabetes medications. Current HbA1c values. Lifestyle interventions being used. Absence of ongoing diabetic complications (or if present, they are noted as sequelae) 5. What about Type I diabetes? Is remission associated? “Honeymoon Phase” vs. Remission Some individuals newly diagnosed with type 1 diabetes may experience a "honeymoon phase": This is a temporary period (weeks to months) where insulin needs to decrease and blood glucose levels may normalize. However, this is not true remission, as the autoimmune process continues and insulin dependence eventually returns. Clinical Scenario Dr. Doctor, Documentation in your visit note indicates the patient has a documented history of type 2 diabetes mellitus, but current labs show: HbA1c: 5.6% No diabetes medications (e.g., insulin, metformin) currently prescribed Patient reports lifestyle changes (e.g., diet and weight loss) No hyperglycemia documented during this admission or recent visits Query Based on the clinical picture, can you please clarify the patient’s current diabetic status? ☐ Type 2 diabetes mellitus – continue to document and treat as active ☐ History of type 2 diabetes mellitus, currently in remission (no medications, normal glucose values) ☐ Other: ________________ References: American Diabetes Association. Standards of Care in Diabetes—2024: Section 2 and Section 6. 2024. Section 2: https://pubmed.ncbi.nlm.nih.gov/38078586/ Full guidelines: https://professional.diabetes.org/standards-of-care Section 6: https://diabetesjournals.org/care/article/47/Supplement_1/S111/153951/6-Glycemic-Goals-and-Hypoglycemia-Standards-of PMC version: https://pmc.ncbi.nlm.nih.gov/articles/PMC10725808/ Buse, John B., et al. “How Do We Define Cure of Diabetes?” Diabetes Care, vol. 32, no. 11, 2009, pp. 2133–2135. DOI: 10.2337/dc09-9036. PubMed: https://pubmed.ncbi.nlm.nih.gov/19875608/ PMC: https://pmc.ncbi.nlm.nih.gov/articles/PMC2768219/ Centers for Medicare & Medicaid Services. ICD-10-CM Official Guidelines for Coding and Reporting 2026. 2025. https://www.cms.gov Centers for Medicare & Medicaid Services. IPPS 2026 Proposed Final Rule. 2025. https://www.cms.gov
Stay ahead with UASI Coding Tips section, featuring practical advice, industry updates, and best practices to enhance your coding accuracy and efficiency.
The SURE Procedure (Steerable Ureteroscopic Renal Evacuation) is a minimally invasive technique for kidney stone management using the Controlled Vacuum Assisted Clearance (CVAC) system. This single-use device enables continuous irrigation and aspiration during laser lithotripsy, enhancing stone fragment clearance from the renal collecting system.
Social Determinants of Health (SDOH) play a major role in patient outcomes and are increasingly important in value-based care and quality reporting. CMS and payers are leveraging SDOH codes to measure population health, address equity, and adjust risk. For coders, this means capturing SDOH in inpatient records has never been more impactful. Main Content The ICD-10-CM Z55–Z65 category includes codes that describe social risk factors such as housing instability, food insecurity, lack of transportation, and financial hardship. While these factors may not always affect DRG assignment directly, they provide critical insight into patient care complexity and resource needs. Common Pitfalls: Assuming SDOH doesn’t matter for inpatient cases: These codes may influence risk adjustment and quality metrics, even if they don’t change DRG assignment. Overlooking non-provider documentation: Coders can use SDOH documented by clinicians other than the physician (e.g., nurses, case managers, social workers), per official guidelines. Incomplete capture: Many records include valuable SDOH information in case management or discharge planning notes that coders may overlook. Example: Documentation: Case manager notes that the patient has “housing instability” and lacks access to medications due to cost. Assign: Z59.01 – Sheltered homelessness (if specified) or Z59.89 – Other problems related to housing and economic circumstances. Assign: Z59.6 – Low income if financial hardship is documented. These codes do not shift DRG, but they support accurate risk adjustment and better reflect the patient’s care needs. Actionable Tips: Always review social work, case management, and discharge planning notes for SDOH documentation. Capture all relevant SDOH Z-codes when documented by qualified healthcare team members. Educate providers and staff on the importance of documenting SDOH clearly and consistently. Remember: While SDOH may not change the DRG, they support value-based care models and health equity initiatives. References CMS: Social Determinants of Health Coding Guidance ICD-10-CM April 1 2025 Guidelines for Coding and Reporting
In neuroimaging, “extra-axial” doesn’t mean outside the skull, it means outside the brain parenchyma (the brain tissue itself) but still inside the skull. Intra-axial = within the brain tissue (e.g., gliomas, abscesses). Extra-axial = outside the brain tissue but within the cranial cavity (e.g., meningiomas, metastases on the dura, arachnoid cysts, subdural hematomas). So: Outside the skull would be extracranial. Extra-axial means the lesion is intracranial but not in the brain substance. A simple way to remember: Axial = brain substance Extra-axial = outside the brain substance, but inside the head Looking further into a Transcalvarial mass – A transcalvarial mass is a lesion that extends through the calvarium (skull bones), connecting the intracranial (inside the skull) compartment with the extracranial (outside the skull) space. Key points: The calvarium = the dome-like skull bones that encase the brain. "Transcalvarial" = crossing through the calvarium. Seen with aggressive tumors, metastases, or sometimes infections that erode bone. Imaging will often show a continuous mass that breaches both the inner and outer tables of the skull. So, compared to extra-axial (inside skull, outside brain), a transcalvarial mass goes a step further — it escapes the skull. The question is – what is this type of biopsy considered to be? This is one of those “it depends” situations in coding, because a transcalvarial mass spans both intracranial and extracranial compartments. General coding logic: Intracranial procedures (craniotomy/craniectomy approaches, brain or meningeal biopsies) are coded under intracranial biopsy codes. Extracranial procedures (scalp, subcutaneous, or skull-only masses) are coded with extracranial biopsy codes. For a transcalvarial mass, the deciding factor is where the biopsy specimen is obtained: If the surgeon biopsies the intracranial portion (inside the dura or cranial cavity) → code as intracranial. Some Examples: 00B00ZX – Excision of brain, open approach, diagnostic. 00B73ZX – Excision of cerebral hemisphere, percutaneous approach, diagnostic. 00B24ZX – Excision of dura mater, percutaneous endoscopic approach, diagnostic. If the biopsy is from the extracranial portion (outside the skull or superficial component) → code as extracranial. Some Examples: 0JB00ZX – Excision of scalp subcutaneous tissue and fascia, open approach, diagnostic. 0HB1XZX – Excision of facial skin, external approach, diagnostic. 0QB00ZX – Excision of skull (cranial bone), open approach, diagnostic. If documentation doesn’t specify, query the provider, because the coding pathway hinges on the biopsy site. References: Centers for Medicare & Medicaid Services, & National Center for Health Statistics. (2025). ICD-10-PCS official guidelines for coding and reporting, FY 2025. U.S. Department of Health & Human Services. https://www.cms.gov/medicare/icd-10/2025-icd-10-pcs American Hospital Association. (2017). Biopsy coding when lesions cross boundaries. Coding Clinic for ICD-10-CM/PCS, 4th Quarter, 28–29. American Hospital Association. (Ongoing). Coding Clinic for ICD-10-CM/PCS. American Hospital Association. Greenberg, M. S. (2020). Handbook of neurosurgery (9th ed.). Thieme.
With CMS’s push towards greater clinical granularity and documentation specificity, the FY 2026 ICD-10-CM Coding Guidelines, which go into effect October 1, 2025, introduces over 487 new diagnosis codes, revises 38, and deletes 28 codes. This is nearly doubling the volume of new codes over FY 2025. One of those major changes involves how coders select and sequence human immunodeficiency virus (HIV) codes. These changes to the guidelines, in section I.C.1.a.2, include various scenarios involving patients before, during, and after an HIV diagnosis. I.C.1.a.2(a) tells you to assign B20 Human immunodeficiency virus [HIV] disease when physician documentation indicates the patient has acquired immunodeficiency syndrome (AIDS), HIV, “or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from the patient’s HIV positive status.” I.C.1.a.2(c) adds clarification that you can assign B20 as a secondary diagnosis for patients with HIV who have been admitted “for an unrelated condition (such as a traumatic injury).” Per the guideline revision, the same is now going to be true for “other documented conditions.” I.C.1.a.2(e) clarifies use of Z21 Asymptomatic human immunodeficiency virus [HIV] infection status. You are told to apply the code when, “‘HIV positive,’ ‘HIV test positive,’ or similar terminology is documented, and there is no documentation of symptoms or HIV-related illness.” I.C.1.a.2(f) still tells you to assign R75 Inconclusive laboratory evidence of human immunodeficiency virus [HIV] for patients with inconclusive serology of HIV; however, the language “but no definitive diagnosis or manifestations of the illness” has been deleted. Patients previously diagnosed with HIV continue to assign B20, but now the diagnosis will have to be documented and not “previously known,” per guideline revision. I.C.1.a.2(h) tells you to assign O98.7 Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium only “when a patient presents during pregnancy, childbirth or the puerperium with documented symptomatic HIV disease or an HIV related illness.” Also assign Z21 for pregnant patients, patients giving birth, and for patients during the puerperium who are either HIV-positive or who have documented asymptomatic HIV. I.C.1.a.2(i), the language changes from “If a patient is being seen to determine his/her HIV status,” to “If a patient without signs or symptoms is tested for HIV.” Additionally, for patients with signs and symptoms presenting for testing, you are now told not to report Z11.4 Encounter for screening for human immunodeficiency virus [HIV]. I.C.1.a.2(j) provides revised instructions for reporting HIV-positive patients who are being treated with an antiretroviral medication. In FY 2026, assign Z21 “in the absence of any additional documentation of HIV disease, HIV-related illness or AIDS.” Practical Application Documentation specificity is critical Look for exact terms (“HIV positive,” “AIDS,” “HIV disease,” “asymptomatic HIV”). Query if unclear. Sequence by admission reason HIV-related = B20 as principal. Unrelated dx = that condition is principal and B20 secondary. Never revert from B20 Once HIV-related illness is documented, always use B20 on future encounters. Apply pregnancy rules Use O98.7 first, then B20 or Z21 based on symptoms/illness. Add management/prevention codes Use Z79.899 for antiretrovirals Z29.81 for PrEP (pre-exposure prophylaxis); any risk factors should also be coded. References Centers for Medicare & Medicaid Services. (2025, October 1). FY 2026 ICD‑10‑CM official guidelines for coding and reporting [PDF]. U.S. Department of Health and Human Services. Retrieved from: CMS.gov American Academy of Professional Coders. (2025, June 16). Coding update: FY 2026 ICD‑10‑CM official guidelines released. AAPC. Retrieved from: aapc.com
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