Enhance Your Accuracy with Expert Coding Tips

With the FY 2026 update, ICD-10-CM adds more specificity for egg allergies and reactions — especially distinguishing tolerance vs reactivity to baked egg. Here are the key new (or revised) codes: T-codes (for adverse reactions / anaphylaxis) - These go in Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (T66–T78 etc.):

New ICD-10 Codes for Inflammatory Breast Cancer (IBC) – Effective October 1, 2025 As of October 1, 2025, three new ICD-10 codes are now available for use to improve accuracy in reporting Inflammatory Breast Cancer (IBC). Coders should begin applying these codes to ensure precise documentation and compliance with current coding standards. C50.A0 – Malignant inflammatory neoplasm of unspecified breast Used when documentation confirms inflammatory breast cancer (IBC) but does not specify which breast is affected; supports accurate reporting when laterality is not documented. C50.A1 – Malignant inflammatory neoplasm of left breast Identifies confirmed inflammatory breast cancer involving the left breast, allowing precise coding that reflects the disease’s location and aids in treatment tracking. C50.A2 – Malignant inflammatory neoplasm of right breast Used to report inflammatory breast cancer of the right breast, improving data accuracy for diagnosis, outcomes monitoring, and research purposes. IBC is a rare but aggressive form of breast cancer, accounting for approximately 1–5% of cases in the U.S. Unlike typical breast cancers, IBC often presents without a detectable lump. Instead, symptoms include: Skin changes such as redness, swelling, or bruising “Peau d’orange” texture (pitted skin resembling an orange peel) Tenderness or burning sensation Due to its atypical presentation, IBC is frequently misdiagnosed as mastitis and often detected at advanced stages (III or IV). It disproportionately affects women under 40, particularly African American and Black women, and is associated with excess body weight. Previously, providers had limited options for coding IBC, often defaulting to malignancy by site breast cancer codes without specifying type. These new codes will enhance clinical documentation, support better tracking of disease progression, and improve access to appropriate treatment. Thanks to advocacy efforts by the IBC Research Foundation and Susan G. Komen, these updates aim to improve data collection and advance research. Resources for Providers: IBC Scoring System Tool https://www.komen.org/ibc-calculatory-intro/ IBC Provider Guide (PDF) https://www.komen.org/wp-content/uploads/IBC_Guide_082824.pdf

With many states legalizing marijuana, “recreational marijuana use” has been appearing in physician documentation more frequently. Is this coded regularly in the same way that drug abuse and dependence is? The answer is in the coding guidelines for Chapter 5 in Section II.5.b.3 “the codes for unspecified psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-,F15.9-, F16.9-, F18.9-, F19.9-)… are to be used only when the psychoactive substance use is associated with a substance related disorder (chapter 5 disorders such as sexual dysfunction, sleep disorder, or a mental or behavioral disorder) or medical condition, and such a relationship is documented by the provider.” This guideline means that merely the documentation of drug/alcohol use alone is not enough to require coding. A good example of when alcohol use would be coded is if a patient has alcoholic cirrhosis and only alcohol use is documented. The alcohol use would be coded since there is an associated medical condition as described in the guideline. Coding clinic 2nd quarter 2018 pg 11 provides further guidance on recreational marijuana use. Coding drug use in a pregnant patient, however, requires different guidelines: Per coding clinic 2nd quarter 2018 pgs 10-11 the drug use complicating pregnancy is coded for any drug use during pregnancy. Per the coding guidelines “It is the provider’s responsibility to state that the condition being treat is not affecting the pregnancy”. Drug use DISORDER is a different diagnosis and is coded differently: Per coding guideline Section II.5.b.1 “mild substance use disorders… are classified to the appropriate codes for substance abuse…and moderate or severe substance use disorders…. are classified to the appropriate codes for substance dependence.” Therefore, we have guidance that if mild drug use disorder is documented we code this as drug abuse, and if moderate or severe drug use disorder is documented we code this as drug dependence. The same applies to alcohol. If drug use disorder is documented without a severity, we cannot assume the severity and a query must be placed. Sources: AHA Coding Clinic for ICD-9-CM and ICD-10-PCS ICD-10-CM Official Guidelines for Coding and Reporting FY 2025

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

Kerecis, is the company pioneering the use of sustainably sourced fish skin in cellular therapy and tissue regeneration. In total, nearly 200 million people in the United States are now covered under commercial insurance plans that recognize fish skin grafts as medically necessary for chronic wound care. According to the Kerecis website, this graft “promotes healing with minimal impairment of functionality and positive cosmetic outcomes. The product is homologous to human skin and when applied to damaged tissue such as burns or wounds, helps top support the body’s own cells to regenerate tissue.” Coding Clinic has released official guidance regarding Kerecis graft application in the fourth quarter of 2024. Their guidance tells us to report this application as replacement of skin with nonautologous tissue, full thickness, external approach. ( ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2024 Page: 65) CMS has released an LCD regarding the covered diagnosis for this unique skin regeneration. This procedure requires a dual diagnosis requirement. When reporting E08.621, E09.621, E10.621, E11.621, E13.621, one of the following must be reported with it to identify the site and severity of the ulcer : L97.411, L97.412, L97.415, L97.416, L97.421, L97.422, L97.511, L97.512, L97.515, L97.516, L97.521, L97.522, L97.525, or L97.526. References: American Hospital Association. (2024). ICD-10-CM/PCS coding clinic, fourth quarter 2024 (Vol. 11, No. 4, p. 65). Chicago, IL: American Hospital Association. Centers for Medicare & Medicaid Services. (n.d.). Local Coverage Determination (LCD): Skin substitute grafts/cellular and tissue-based products for the treatment of diabetic foot ulcers and venous leg ulcers (L36377). U.S. Department of Health and Human Services. Retrieved September 5, 2025, from https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=36377 Centers for Medicare & Medicaid Services. (n.d.). Article: Billing and coding: Skin substitute grafts/cellular and tissue-based products for the treatment of diabetic foot ulcers and venous leg ulcers (A57680). U.S. Department of Health and Human Services. Retrieved September 5, 2025, from https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57680 Kerecis. (n.d.). Intact fish skin for tissue regeneration. Kerecis. Retrieved September 5, 2025, from https://www.kerecis.com

Hypoglossal Nerve Stimulant placement is mainly used to treat obstructive sleep apnea. This is a surgically implanted device that stimulates the nerves that move the tongue and open the airway while a person sleeps. This device is recommended when a CPAP device is not tolerable. As of 2023, the only hypoglossal nerve stimulator that is approved by the Food and Drug Administration is the Inspire device. Parts to the System Include : Breathing monitor, Pulse generator, Electrode(s), Hand-held remote control Two Different Models *Inspire IV: three implantable components – the Inspire device, a stimulation lead and a respiratory sensing lead *Inspire V: (newer version) eliminates the separate respiratory sensing lead, resulting in a simpler two-component system. Covered by most insurances, however commercial insurances may only cover the procedure for people with BMI of 32 or less. For Medicare there is a dual diagnosis requirement: G47.33 Obstructive Sleep Apnea (adult)(pediatric) BMI code (Z68.1-Z68.34) Corresponding CPT’s: 64582 – Implant Inspire IV or 64568 – Implant Inspire V 64583 – Revision/Replacement of breathing & nerve stimulator electrodes 64584 – Removal of device (electrodes & generator) 61885 - Revisions from Inspire IV to Inspire V 61886 - Generator replacement with connection to 2 or more electrodes * Append modifier 52 in instances where only a portion of the device listed in the description is revised/removed (e.g., revision of breathing sensor lead only or revision of stimulation lead only) Practical Application Confirm payer coverage, especially BMI limits for commercial plans. Review the operative note to determine if the full device or only a component was revised (use modifier 52 if partial). Select the correct CPT based on Inspire model (IV vs. V). For Medicare, always include both OSA and BMI codes. Sources: Tampa General Hospital. (2025, June). Tampa General Hospital and USF Health among first U.S. sites to offer new Inspire V system for treating obstructive sleep apnea. Tampa General Hospital News. https://www.tgh.org/news/tgh-press-releases/2025/june/tgh-and-usf-health-among-first-us-sites-to-offer-new-inspire-v-system Karen Zupko & Associates, Inc. (2025, August 14). Coding for Inspire. KZA Coding Coaches. https://www.kzanow.com/coding-coaches/coding-for-inspire-8-14-25 Johns Hopkins Medicine. (n.d.). Hypoglossal nerve stimulation implant for sleep apnea. Johns Hopkins Medicine Health. https://www.hopkinsmedicine.org/health/conditions-and-diseases/obstructive-sleep-apnea/hypoglossal-nerve-stimulation