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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!
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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.
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
