2026 ICD-10 Coding Tip Guidebook Now Avilable!
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Coding Tips
Welcome to UASI's Coding Corner! We're here to make your medical coding journey smoother and more enjoyable with our friendly and practical tips. Whether you're just starting out or you've been in the field for years, you'll find something useful here. Our expert advice, handy tricks, and up-to-date industry insights are all geared towards helping you code more accurately and efficiently. So, grab a cup of coffee, get comfy, and explore our tips to take your coding skills to the next level!
Type 2 Diabetes in Remission — Understanding the New E11.A Code for FY 2026
Hyperbaric Oxygen Therapy (HBOT) Coding
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.
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.
Learn how capturing social determinants of health (SDOH) in inpatient coding improves accuracy, supports equity, and strengthens quality and reimbursement outcomes.
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.
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