Gestational Diabetes definition : Any pregnant person that shows abnormal glucose tolerance that was not present prior to the pregnancy. The American College of Obstetricians and Gynecologists (ACOG) define GDM as "a condition in which carbohydrate intolerance develops during pregnancy.” Preexisting (pregestational) diabetes refers to type 1 or 2 diabetes diagnosed before pregnancy. Common Risk Factors: GDM in a prior pregnancy Family history of diabetes Pre-pregnancy BMI ≥30 kg/m2, significant weight gain in early adulthood or between pregnancies, or excessive gestational weight gain during the first 18 to 24 weeks of pregnancy Maternal age >/=35 years of age Key Points for Accurate Documentation Specify Diagnosis Clearly Use the term “Gestational Diabetes Mellitus (GDM)” and indicate if it is diet-controlled (A1) or insulin/medication-controlled (A2). Avoid vague terms like “borderline diabetes” or “glucose intolerance.” Document Diagnostic Basis Include OGTT results or note that diagnosis was based on ADA/ACOG criteria (e.g., abnormal 1-hour or 3-hour glucose tolerance test). Capture Clinical Significance Note any maternal or fetal complications (e.g., polyhydramnios, macrosomia, preeclampsia). Document treatment plan: diet modification, insulin, oral agents, or glucose monitoring. Differentiate from Pre-existing Diabetes Confirm that hyperglycemia was first recognized during pregnancy. If diabetes existed before pregnancy, code as pre-gestational diabetes. Postpartum Follow-up Indicate if postpartum glucose testing or counseling for future diabetes risk was provided. Why It Matters: Precise documentation supports accurate ICD-10 coding (e.g., O24.41–O24.43), reflects severity of illness, and impacts quality metrics and reimbursement. AHRQ’s Maternity Care Measure Set includes post-partum glucose careening for gestational diabetes patients in Measure 10 – Post-Partum Follow-up and Care Coordination. This measure applies to all patients regardless of age, who gave birth during a 12-month period seen for post-partum care visit before or at 8-weeks of giving birth. There are no exceptions. References: ACOG/National Committee or Quality Assurance. (2012). Maternity Care Performance Measures Set. Maternity Care Performance Measurement Set American College of Obstetricians and Gynecologists. (2018). Gestational Diabetes Mellitus. Practice Bulletin Number 190. Gestational Diabetes Mellitus | ACOG Centers for Medicare and Medicaid Services. (2025). Official Guidelines for Coding and Reporting. ICD-10-CM October 2025 FY26Guidelines Diabetes Care 2025;48(Supplement_1):S306–S320 https://doi.org/10.2337/dc25-S015 Durnwald, C. (2025). Gestational diabetes mellitus: Screening, diagnosis, and prevention. UpToDate.

Definition : Acute Kidney Injury (AKI) is an abrupt decline in kidney function, leading to retention of waste products, electrolyte imbalance, and fluid dysregulation. It is classified based on etiology and severity. 1. Types of AKI by Etiology Pre-Renal AKI Cause: Decreased renal perfusion without intrinsic kidney damage. Examples: Hypovolemia (dehydration, hemorrhage). Hypotension/shock (sepsis, cardiogenic shock) Heart failure, liver failure Documentation Tip: Specify underlying cause (e.g., “AKI due to hypovolemia from GI bleed”). Intrinsic (Intra-Renal) AKI Cause: Direct damage to kidney tissue. Examples: Acute Tubular Necrosis (ATN\) – ischemia or nephrotoxins Acute Interstitial Nephritis (AIN) – drug-induced, autoimmune Glomerulonephritis Documentation Tip: If ATN or AIN is suspected, document specifically (e.g., “AKI secondary to ATN from contrast exposure”). Post-Renal AKI Cause: Obstruction of urine flow. Examples: Ureteral obstruction (stones, tumors) Bladder outlet obstruction (BPH, neurogenic bladder) Documentation Tip: State the obstructive cause (e.g., “AKI due to bilateral ureteral obstruction from stones”). 2. Diagnostic Criteria (KDIGO) Increase in serum creatinine by ≥ 0.3 mg/dL within 48 hrs, OR Increase in serum creatinine to ≥ 1.5 times baseline within 7 days, OR Urine output < 0.5 mL/kg/hr for 6 hrs 3. Severity Staging Stage 1: 1.5–1.9 × baseline creatinine or ≥ 0.3 mg/dL rise Stage 2: 2.0–2.9 × baseline Stage 3: ≥ 3 × baseline or creatinine ≥ 4.0 mg/dL or dialysis required 4. CDI and Current Coding Guidance Avoid vague terms like “renal insufficiency”; use “acute kidney injury” or “acute renal failure” (interchangeable per coding). Always link AKI to the underlying cause (e.g., sepsis, dehydration, obstruction). If ATN or AIN are present, document explicitly (these are MCCs). Do not abbreviate AKI without context; clarify in the first mention. Trend labs and urine output to support diagnosis before querying. Assign code N17.0, Acute kidney failure with tubular necrosis, with a POA of N for documentation of a patient with AKI on admission who then develops ATN after admission. For a case of acute kidney injury (AKI) due to acute tubular necrosis (ATN) secondary to contrast-induced nephropathy, the correct coding assignment is N17.0 for acute kidney failure with tubular necrosis, N14.11 for contrast-induced nephropathy, and T50.8X5A for adverse effect of diagnostic agents, initial encounter. This combination accurately reflects the underlying cause, the specific kidney injury type, and the adverse effect of the contrast agent. Pro Tip: AKI impacts severity of illness and quality metrics (e.g., PSI-10 Post-Op AKI). Accurate documentation ensures correct DRG assignment and patient safety. References: AHA Coding Clinic, Third Quarter 2025, p. 22 AHA Coding Clinic, Fourth Quarter 2022, p. 33 Centers for Medicare and Medicaid Services. (2025). Official Guidelines for Coding and Reporting. www.cms.gov. Fatehi, P., & Hsu, C-Y. (2024). Evaluation of acute kidney injury among hospitalized adult patients. UpToDate. Palevsky, P. M. (2025). Definition and staging criteria of acute kidney injury in adults. UpToDate. Prescott, L., Manz, J. (2025). The ACDIS Inpatient CDI Pocket Guide. www.acdis.org

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): _______________________

HBOT is described as a treatment that utilizes pure oxygen in a high-pressure environment to aid in healing wounds/tissue that have been damaged by infection, poisoning or injuries. There must be an initial HBOT evaluation and/or consultation by a physician or nurse practitioner (NPP). Physician or Non-Physician Practitioner (NPP) order for date of service, if applicable. The documentation is very specific to the prescribing of HBOT as well as the treatment rendered. Progress notes HBO clinic/progress notes Clinic/hospital/progress notes prior to starting HBO, if applicable Support of the initial wound/condition etiology Support of prior history of treatment for the condition/wound(s), if applicable HBO Treatment plan Atmospheric pressures Rest/Air breaks Frequency and number of dives Blood glucose monitoring, if applicable Wound assessments, if applicable Evaluation of progress HBO dive logs/treatment records Documentation should include minutes completed during HBO treatment Documentation should support when blood glucose measurements are taken and the results, if applicable Wound treatment records or wound flow sheets supporting measurable signs of healing Wound measurements, if applicable Subjective findings regarding wound, if applicable Diabetic wound(s) required documentation: Wagner grade classification (must be Wagner grade III of higher) with diagnostic testing to support Wagner grade; Patients have type 1 or type 2 diabetes and lower extremity wound due to diabetes. Documentation supporting prior failed treatment using standard wound care. Documentation supporting there were no measurable signs of healing for at least 30 consecutive days of treatment when using standard wound therapy. Evaluation of wound(s) at least every 30 days during administration of HBO therapy that supports evidence of measurable signs of healing Standard diabetic wound care therapy documentation required prior to starting HBO: Assessment of patient's vascular status and correction of problems, if applicable Support for optimization of nutritional status Support of optimization of glucose control Support of debridement of the devitalized tissue Support of the wound care management that includes maintenance of a clean, moist bed of granulated tissue with appropriate moist dressing Support of appropriate off-loading Support of treatment to resolve infection There must be separate documentation for an evaluation and management (E&M) service if provided on the same date of service as treatment. The patient must be provided an Advance Beneficiary Notice of Noncoverage (ABN), if applicable. Sources: Cleveland Clinic. (n.d.). Hyperbaric oxygen therapy. Cleveland Clinic. Mayo Clinic. (n.d.). Hyperbaric oxygen therapy. Mayo Foundation for Medical Education and Research. Centers for Medicare & Medicaid Services. (n.d.). National coverage determination (NCD) for hyperbaric oxygen therapy (20.29). U.S. Department of Health and Human Services.

Chronic inactive gastritis is often noted in an EGD result or path report. It is important to still code this, even though it is “inactive” as it can still greatly affect the patient’s quality of life and can increase the risk of developing stomach cancer in the future. In some cases, untreated inactive gastritis can progress to active gastritis, which may require more aggressive treatment. INACTIVE VS ACTIVE Gastritis Inactive: chronic inflammation of stomach lining without tissue damage or injury Active: chronic inflammation with presence of neutrophils in stomach lining, with ongoing tissue damage or injury (example: with infection or ulceration) The neutrophils being there show the immune system is attempting to actively fight an issue. ICD-10 Codes don’t differentiate between active & inactive gastritis: K29.50 chronic gastritis without bleeding K29.51 chronic gastritis with bleeding Add code for infection, if that applies (example: B96.81 for Helicobacter pylori) Other specified gastritis has specific codes (atrophic, superficial, alcoholic, etc. – see ICD-10 index) What This Means in Practice Code chronic gastritis, even if documented as inactive Code to highest specificity according to ICD-10-CM index and tabular Code any secondary conditions that further explain in detail the patient’s condition Sources: Singh, N. (2023, July 14). Chronic inactive gastritis: Causes, symptoms, diagnosis, and treatment. iCliniq. https://www.icliniq.com/articles/gastro-health/chronic-inactive-gastritis#:~:text=Chronic%20inactive%20gastritis%20is%20a%20type%20of%20gastritis%20marked%20by,vomiting%2C%20and%20loss%20of%20appetite.

The FDA has approved the first cell-based gene therapy for treatment of sickle cell disease in patients 12 and older. CRISPR can be directed to cut DNA in targeted areas, enabling the ability to accurately edit DNA where it has been cut. Think of your DNA as an instruction manual for how your body works. Sometimes, there’s a typo in the manual that causes problems, like sickle cell disease. CRISPR is like a pair of tiny scissors and a GPS system combined. It can find the exact spot of the typo in the DNA and either fix it, remove it or replace it with the correct instructions. In CASGEVY gene therapy, physicians use CRISPR to repair or change these faulty instructions so that cells can work properly again. How Do We Capture This: This treatment is used for patients with recurrent vaso-occlusive crises or with a history of vaso-occlusive events.