Enhance Your Accuracy with Expert Coding Tips

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

CMS has released the FY 2026 ICD-10-CM October 1st updates ushering in the annual set of updates to diagnosis codes used across all care settings. While there are hundreds of changes, a handful are expected to have an outsized effect on reimbursement, case mix index, quality reporting, and value-based payment programs. Below are the most consequential areas and how organizations should prepare.

Since the introduction of ICD-10, spinal fusions have been a topic among coders and auditors. When coding spinal fusions, we typically look for where the instrumentation was placed: pedicles (posterior column) or disc space (anterior column). New technology has been created to treat lumbar spinal stenosis and facet syndrome. This new technology is the Facet FIXation device (FFX). “The FFX®system, placed bilaterally through a posterior surgical approach and spanning and compressing the facet joint interspace, is designed to aid lumbar fusion through bilateral immobilization of the facet joints”. Since this device is not placed in the traditional spinal column locations, ICD-10-PCS does not currently have an accurate or complete PCS code for this type of fusion. Therefore, a new technology code was introduced for this procedure. In Coding Clinic fourth quarter 2024 pg 49, we are instructed to create a code from the XRG fusion of joints table, with a device value of E “facet joint fusion device, paired titanium cages” with the qualifier of A to indicate that this is new technology, group 10.

Hypertensive Emergency is a severe increase in high blood pressure (typically greater than 180 systolic/120 diastolic) with potentially life-threatening symptoms or damage to vital organs. **In FY 2025, new sequencing instructions were added to ICD-10 for hypertensive emergency.**

Many coders still struggle with assigning the seventh character for initial and subsequent encounters. Using these correctly ensures accurate reimbursement and avoids claim denials. When assigning the 7th character for injuries or conditions like fractures, sprains, or open wounds, do not confuse “initial” with the patient’s first visit. Initial Encounter (A) = Active treatment is still being provided – “surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.” Subsequent Encounter (D) = The patient is in the healing or recovery phase, receiving routine follow-up care - “cast change or removal, an X-ray to check healing status of fracture, removal of an external or internal fixation device, medication adjustment, and other aftercare and follow-up visits following treatment of the injury or condition.” In ICD-10-CM, “initial” vs. “subsequent” is about the type of care being provided, not the location (like inpatient vs. outpatient) Use 7th character “A” (Initial Encounter) when the patient is receiving active treatment for the injury – regardless of whether they’re in the ER, surgery, or admitted inpatient. Use 7th character “D” (Subsequent Encounter) once the patient is receiving routine aftercare for healing – even if they are still in the hospital (e.g., rehab or post-op management). 

Optilume is an FDA approved drug-coated balloon, developed by Urotronic, that is inserted via cystoscopy to dilate and treat urethral strictures or stenosis caused by benign prostatic hyperplasia (BPH). It is a minimally invasive procedure that provides immediate relief from the urinary symptoms men can experience with BPH. A CPT code, 52284, was introduced in 2024 which can be used when a cystoscopy with Optilume is performed. The drug on the outer surface of this balloon (paclitaxel), once absorbed, may help maintain the stricture expansion and help improve urinary flow. The balloon is not left inside the patient, but rather taken out after 5 minutes of inflation, leaving the drug to do its job with the rest. Key Points for Coders Use CPT 52284 only when a drug-coated balloon (like Optilume) is used during cystoscopy to treat urethral stricture/stenosis. Documentation must clearly state: Use of Optilume Paclitaxel drug delivery Balloon inflation and removal Do not code separately for the drug Use C1889 for the device code Ensure the diagnosis supports stricture/stenosis, not just BPH. This code is new in 2024—don’t use it for earlier dates. Watch for bundling and use modifiers only if appropriate. Check payer policies for coverage and authorization requirements References: Optilume BPH Catheter System – P220029 | FDA Optilume Optilume® for Urethral Stricture | Urethral Drug Coated Balloon CPT Assistant, February 2024, Volume 34, Issue 2, page 21 Coders Desk Reference

By now, you’ve all seen and coded a leadless pacemaker. Did you know they make dual-chamber leadless pacemakers?