2026 Q1 Coding Updates

We walk through the newest coding guideline and ICD-10 updates that are driving real questions from coders and CDI teams right now. We connect the rule changes to clinical context so you can spot documentation gaps early and code with confidence. 
• sepsis guideline title change and why antibiotic resistance keeps surfacing in reviews 
• drivers of antimicrobial resistance and common clinical risk factors to capture 
• hypertension with heart disease guideline updates and when additional codes apply 
• sequencing considerations for hypertensive urgency, emergency, and crisis 
• new technology updates including lattice stents, newer defibrillator leads, Fontan scaffold advances, obstetrical dilators, and emerging therapies 
• CAR T therapy documentation watchouts and differentiating CRS from SIRS during reviews 
If you have any questions or would like to offer a topic to discuss, please email info at accuityhealthcare.com. 

Originally Published: 5/13/2026

Transcript

Welcome And What Chart Check Solves

SPEAKER_00 0:01

Welcome to Chart Check, Clinical Perspectives for the Middle Revenue Cycle. This podcast delivers insights that drive impact in healthcare information management. Stay current on clinical knowledge, coding updates, and industry trends through expert interviews and conversations with acuity's own physician, CDI, and coding leaders. Clinical perspective. Welcome to Chart Checkout Cycle. This podcast delivers insights that drive impact in healthcare information management. Stay current on clinical knowledge, coding updates, and industry trends through expert interviews and conversations with Acuity's own physician, CDI, and coding leaders.

Sepsis Guideline Title Change Plus Resistance

SPEAKER_03 0:57

So our first coding guideline update here, this is for the chapter-specific coding guidelines. This is just a change in that title from sepsis, severe sepsis, and septic shock infections resistant to antibiotics. We now have that crossed out here. And we'll take a look a little bit at some of those antibiotic-resistant causes while we're here. We have had an influx in some of these questions lately. Brittany, I will pass that over to you.

SPEAKER_02 1:24

Sure. So per the World Health Organization, misuse and overuse are some of the main drivers in the development of drug-resistant pathogens. We also see some microbes can also carry resistance genes, or they can even spontaneously mutate and survive. And since most microbes divide every few hours, they can actually even evolve rapidly and adapt quickly to new environmental conditions. So mutating and allows them to survive in that antimicrobial world. Vanessa, if you can go to the next slide, we'll kind of go over some of those potential risk factors, things we might be looking for in our documentation that puts patients at risk for dart-resistant infections. So things like repeated or prolonged antibiotic exposure, recent healthcare exposures, other chronic comorbid conditions. And these factors all contribute to create an environment for resistant organisms to develop and spread. I have listed some of the more common bacteria associated with deaths from antibiotic resistance, some of the more common superbugs. I won't go over all of them with you, but some of them that we're seeing, E. coli, have reports of increasing resistance to third generation cephalosporins. UTIs caused by E. coli are showing some of that susceptibility to some standard antibiotics. We're probably all too familiar with methacillin resistant Staphylococcus aureus or MERSA. KlebCL is also showing some increased resistance to some of our common antibiotics. And so we're having to use heavier duty drugs. Similarly, with that multi-drug-resistant tuberculosis, we're seeing some resistance to that as well. And though it's still treatable, we're not having to use some second-line drugs, which are more expensive, more toxic, usually less tolerated. And this is where we're seeing a lot of complications from drug-resistant bugs is that we're having to use stronger medications, more severe medication side effects, likely increased risk of severe extended illness or death, longer hospital stays, increased medical costs. And this is again where antibiotic resistance really starts to affect not only our patients, but our healthcare systems.

SPEAKER_03 3:24

Thank you, Brittany.

Hypertension With Heart Disease Coding Clarity

SPEAKER_03 3:25

Our next coding guideline update here is for the hypertensive coding. So this is going to be chapter 9, diseases of the circulatory system, hypertension, and hypertension with heart disease. So here is the update to this coding guideline. We have hypertension with one or more heart conditions, is classified to I-50 heart failure, I-514 myocarditis unspecified, I-5189 other ill-defined heart disease and or which is now or I-51.9 heart disease unspecified, is assigned to a code from category I-11 hypertensive heart disease. And this we use additional codes from category I-50 for heart failure or I-51 for complications and ill-defined descriptions of heart disease to identify the heart condition. Another addition here, we're gonna get just kind of changing um warning here, is hypertension with one or more heart conditions is classified to myocardial degeneration or cardiomegalye is assigned a code from I-11 hypertensive heart disease, but with no additional code to assign the assigned to identify the specific heart condition. So this is one as well that we have gotten a lot of questions from recently, and a lot of clients were talking about the change in that coding guideline. So just touching on this a little bit more so it is becoming more relevant. Um here is kind of how we would need to be breaking down that hypertensive coding. So we have hypertension specified as with kidney disease, with heart disease, with cerebovascular disease, and how these are going to be coded off to the left here. When that is specified as pulmonary hypertension, we have the code from category I-27 with the code for the associated condition or adverse effects of drugs or toxins. And then over here on the right, we can see urgency, emergency, and crisis. Um two parts I wanted to highlight here. That's going to be a code from category I-16 as well as the code for the hypertensive heart disease. That sequencing will be based on the um circumstances of admission. And then one thing, too, that we have received a handful of questions on lately is whether or not accelerated or malignant hypertension equaled hypertensive crisis, urgency, emergency. So remembering that those terms are not interchangeable. Um Brittany, I will pass that over to you.

SPEAKER_02 5:46

Thanks. Um, so as your table showed, Vanessa, we know that hypertension can affect multiple organs. Uh, when we specifically look at hypertensive heart disease, it actually is the number one leading cause of illness and death due to high blood pressure. And it really comes down to what that constant pressure does to the heart over time. Uh, Vanessa, if you can go over to the next slide. I always find pictures are better than words. Uh, so chronic high blood pressure puts a strain on the heart because the heart has to work harder to move the blood forward. And that muscle thickens to compensate, causing a potential left ventricular hypertrophy. Now, initially it's adaptive to help maintain that cardiac output despite that increased resistance, but that thicker muscle then becomes stiff. So the heart doesn't relax as well between beats and it becomes less efficient. And over time, that strain catches up. The heart can weaken and enlarge, it can progress to a dilated cardiomyopathy. And then once the heart's pumping efficiency is really reduced, it can lead to cardiomegaly and heart failure and other really serious cardiovascular complications.

SPEAKER_03 6:45

Thank you, Brittany.

Newborn Observation And Congenital Codes

SPEAKER_03 6:46

Our next guideline update here is for um chapter 16: certain conditions originating in the perenatal period, um observation and evaluation of newborns for suspected conditions not found. This is going to be for Z05, other than on the birth record. And our um guideline here is that a code from category Z05 may also be assigned as a principal or first listed code for readmissions or encounters when the code from category Z38 no longer applies. Codes from category Z05 are for use on healthy newborns and infants, which no condition after study is found to be present. Our final guideline update for today is going to be under chapter 17: congenital malformations, deformations, and chromosomal abnormalities. This is a change in that category there, so it goes from Q00 to QA now. Um and then just to summarize that guideline, codes from chapter 17 may be used throughout the life of the patient if a congenital malformation or deformity has been corrected. A personal history code should be used to identify the history of the malformation or deformity. Although present at birth, a malformation, deformation, or chromosomal abnormality may not be identified until later in life. And whenever that condition is diagnosed by the provider, it is appropriate to use the codes from those categories Q00 to QA. With that, we will move into our ICD 10 CM code updates. Um and we don't have any new codes for this section, but what did change? We have some revisions to index entries, um, revisions to tabular instructions, so excludes and instructional notes. Our coding impact, there's going to be a greater emphasis on correct code selection based on the revised instructional notes and avoiding those excluded code combinations. So ICD 10 PCS code updates.

ICD-10-PCS Updates Through Real Coding QandA

SPEAKER_03 8:41

We did have a handful here. We have 80 new procedure code additions, two procedure code deletions, and zero procedure code revisions. We have a focus on this as well coming up for new technology procedures, device and approach specificity. Um, and our recommendation for coders is to review the tables impacted by the new codes as well as procedure documentation specificity. So starting with our first new code here, this is going to be insertion into the ventricular septum. This is a new code under medical surgical, heart and greet vessels under insertion, ventricular septum, and then we'll have a key a question and answer coming up here as well as some information coming from Britney. So the question asked here, so the question asked to coding clinic, a patient with heart failure with reduced ejection fraction and left bundle branch block underwent insertion of a cardiac resynchronization defibrillator or CRTD. After the pocket was fashioned for the pulse generator, the right ventricular lead was positioned in the right ventricular septum percutaneously, where the helix was deployed. A delivery sheath was advanced and the paced sense lead was brought into the interventricular septum and deployed to deliver left ventricular pacing. Another sheath was advanced, and the right atrial paced sense lead was deployed to the right atrial appendage. The pulse generator was connected to the leads. What are the appropriate code assignments for the insertion of the three leads retrospectively placed into the right ventricular septum, intraventricular septum, and the right atrial appendage? And um the answer to this one here is that we're going to be coding the insertion of the defibrillator lead into the right ventricle percutaneous approach, insertion of the defibrillator lead into ventricular septum percutaneous, and that's going to be for the insertion of the lead into the intraventricular septum to deliver the left ventricular pacing. The third code added here would be insertion of defibrillator lead into the right atrium percutaneous approach for the insertion into that right atrial appendage. Brittany, will you talk to us a little bit about the difference in those pacings?

SPEAKER_02 10:51

Sure. So ventricular septal pacing involves placing a pacing lead into the ventricular septum rather than the more traditional of the right ventricular apex. Again, clinically, right ventricular pacing has been more standard of care, but we're starting to see more septal pacing as gaining traction due to potential benefits of that near-simultaneous activation of both ventricles, which is actually shown to improve electrical synchrony as well as reducing the risk of pacing-induced cardiomyopathy, as well as potentially heart failure hospitalizations. So, really, Vanessa, is that coding clinic question was showing, we just look for that location specification in the documentation. Thank you.

SPEAKER_03 11:30

Our next uh code edition here is for extraction of the omentum and mesentery. Um, this is going to go into that gastrointestinal system, and we'll break down the anatomy for that here in just a moment. But the two body parts here will be omentum or mesentery. We have approaches open or percutaneous, endoscopic, and then no device and no qualifier here. So the question asked for the coding of this a patient with uh endometrial cancer provide presented for a hysterectomy, tube removal, and mesenteric tumor debulking with the sonopet ultrasonic surgical aspiration. A midline incision was made from the pubic symphysis to the umbilicus. Following a sharp and blunt dissection, a modified radical hysterectomy and tube removal was performed. The sonopet ultrasonic aspirator was then used to aspirate the small bowel mesenteric tumor, and the procedure was completed and the abdomen was closed. In this, they're asking what is the correct GCS code for the cavitron ultrasonic surgical aspirator to defaulte the mesenteric tumor? And our answer provided was to code extraction of mesentery open approach for the ultrasonic aspiration removal of the mesenteric tumor. Brittany, I will pass that over to you for that anatomy.

SPEAKER_02 12:44

Sure. Um so the omentum is that double layer of fatty tissue that covers and supports the intestines and organs in the lower abdomen. And then the mesentery is the tissue that suspends your intestines to the posterior abdominal wall. Now we saw in there that the omental and mesenteric resections, they're often part of radio, I'm sorry, cytoreductive or debulking surgeries in patients with malignancies like ovarian cancers, colorectal, gastric cancers, endometrial cancers. And its goals are not only to reduce the turmoil burden, but to improve the effectiveness of additional treatments like chemotherapy or radiation therapy, as well as to hopefully relieve some of the patient's symptoms like abdominal pain and obstruction. Again, from a coding perspective, we just want to be mindful of the extent and sight of that tissue removal, any additional procedure codes for tumor extractions, uh if pathology reports are sent for these types of um for staging of the cancer. So just be mindful of those things.

SPEAKER_03 13:43

Thank you. Next code update here is for drainage of hepatobiliary system and pancreas. Here we have two qualifiers added, transmural and transpapillary, and we will break down the differences in those two here.

SPEAKER_02 14:00

So endoscopic drainage methods are actually emerging as alternative treatments, particularly for acute catoley cystitis in our more high-risk surgical patients. So in transpapillary gallbladder drainage, the biliary tree is accessed from an ERCP, and then a wire is passed through the cystic duct into the gallbladder and the stencil place for drainage. So some documentation keywords we might be seeing is that ERCP is the approach, as well as cannulation of the cystic duct as a patent cystic duct is required for this procedure. Now, in comparison, a transmural approach goes directly through the wall of the GI tract and into the gallbladder. And so using ultrasound guidance, a connection is made between the gallbladder and then either the stomach or the duodenum, and then a stent is placed. So this will often be used if the cystic duct is blocked, maybe the transpapillary access fail because of the tumor blocking it, or maybe altered anatomy. One thing that you may see in the documentation is lumen-opposing metal stent. Um, this has actually emerged as one of the preferred stents for this, as it has a high technical and clinical success rate with minimal adverse events. Can be used in other things, but gonna be more common in that transmural approach.

SPEAKER_03 15:12

Our next code update here is for um transfer of the bladder. So this was a new code added here for one of the questions that was posed, and I will pull that up here next. Um, so this audition is gonna allow the creation of codes that describe the transfer of the bladder tissue for a ureteral reconstruction. So the question asked here was a patient with a history of anal cancer presents uh for the right ureteral reimplantation with a boari flap reconstructed due to ureteral structure likely secondary to that radiation. An infrapubic midline incision was made and the right ureter defect was identified. The ureter was then mobilized and transected in preparation for reimplantation. The tongue-shaped flap with a five-centimeter wide base and eight centimeter length was harvested from the anterior surface of the bladder. Then the ureter was sewn to uh the bore bladder flap and attached to the distal right ureter. What was the correct code assignment for the ureteral reimplantation with the flap? So the advice here is to assign a code for transfer bladder to the right ureter open approach. Um, and they just remind us here that the correct root operation for the procedure is transferring. Um, I will hand her back to you. Thank you.

SPEAKER_02 16:30

Thanks. Uh so ureteral reconstruction is used when there's damage to the ureter from maybe either injury during a pelvic or colorectal surgery, uh, prior scar from endoscopic procedures, uh, cancers of the urinary tract, or even congenital or inflammatory disorders. And when the damage section is too long to simply reconnect, or maybe their ureteral mobility is too limited, the surgeon needs another way to bridge that gap. And one of the options is to use the patient's own bladder tissue. So in this bore flap procedure, the surgeon takes a portion of the bladder, mobilizes and tubularizes that flap of bladder tissue so it can cover the distance, and the flap is then connected to that healthy portion of the ureter. We may also see something called a psoas hitch, uh, which can be used with this procedure as well. And it basically entails mobilizing the bladder towards that affected kidney and fixing or hitching it to the psoas muscle.

SPEAKER_03 17:26

Thank you. Next one here, and uh we've got lots of interesting information coming up on this one here, uh, is reception of the prostate with the intact capsule. So this is going to be adding that qualifier of E for capsule intact. And um we we heard some conflicting parts to this. So, Brittany, I will give that back to you.

SPEAKER_02 17:44

Um, so the prostate capsule is not really a true capsule in the fact that it's not a distinct, separate structure, but rather it's that non-glandular, thin micro, sorry, fibromuscular band of tissue that surrounds the prostate tissue. And it's really kind of inseparable from the underlying prostatic stroma. So, in cases of benign prostatic hypertrophy, when maybe a transurethral procedure wouldn't give much relief from the obstruction, so maybe the prostate's too large, or maybe it would be done because other concurrent pathologies that require management, like bladder stones, need to be done. A simple prostatectomy may be indicated. And in this procedure, basically the inside of the prostate gland is removed, but leave the capsule intact. Um, so it's basically like scooping out an orange from the orange peel. And by leaving the capsule intact, uh, the nerves next to the seminal vesicles are preserved to hopefully help reduce the risk of erectile dysfunction and urinary incontinence.

SPEAKER_03 18:44

Thank you, Brittany.

New Technology Codes Stents Fontan CAR-T

SPEAKER_03 18:46

Okay, we'll go ahead and move into our section next for new technology. Um, starting with the open structure lattice stent. Um so I will let Brittany give all of the clinical side on this, of course, but this is um going to be added to table X27, diletion of cardiovascular system. The device value would be C for intraluminal device, open structure polymer lattice, and the body part value two for the inferior vena cava and iliocaval confluence. Um, those will be added to the approach value of three for percutaneous. So that addition allows for the reporting of the insertion of the open structure polymer lattice stent to treat symptomatic obstructions at the inferior vena cava with or without obstruction of the iliofemoral veins. Ritney, I will pass her over.

SPEAKER_02 19:38

Thanks. So our peripheral venous system brings our deoxygenated blood back to the heart through one-way valves and it works against gravity. So obviously, the patency of these veins is essential for that proper blood flow. So this stent is actually the first FD-approved open structure polymer lattice stent device that's indicated for the treatment of symptomatic inferior vena cava obstruction with or without that iliofemoral involvement. Now, terms that we might see in the documentation, we've kind of already been saying it opener polymer lattice, lattice stent, self-expanding wireframe, uh, expanded polymer lattice. And all of these terms really truly translate into why this stent is more beneficial, is because it mimics that natural iliocaval motion. So hopefully it avoids kinking. Uh, it maintains that lumen integrity to help with blood flow, and it provides that high flexibility in an area that has a lot of repetitive movement like bending and torsion, and that hopefully helps reduce that fracture risk.

SPEAKER_03 20:38

Thank you. Sure. Next we have the luminless small diameter defibrillator lead. So um let's look at this coding portion here. So this will be in table X to H for insertion of cardiovascular system. Device value here will be G for defibrillator lead, luminless small diameter added to the body part value, M for ventricular septum, and V for right ventricle. Approach value here is going to be percutaneous. And this will add that code to capture the insertion of a luminous small diameter defibrillator lead into the ventricular septum as well as the right ventricle.

SPEAKER_02 21:19

So this device is indicated for single use in right ventricular, uh, the right ventricle for pacing, sensing, cardioversion, and defibrillation therapies to treat patients who have experienced or certainly at higher risk of developing life-threatening ventricular tachyarrhythmias. Um, now, as the name says, they're uh small in size, which actually makes it suitable for even some of our select pediatric adolescent patients, as well as those that maybe have undersized or narrowed vessels or other heart changes. And the small size has also potentially been found to reduce the risk of lead related complications. So things like vascular occlusion or tricuspid valve complications. Now, having a catheter delivered lead. Allows physicians to get more specific on placement. And because the device is luminless and avoids a stylet, it provides a more targeted lead delivery. So hopefully higher defibrillation efficiency. And these are terms or things that we can potentially expect to see in our documentation. So again, small size, catheter delivered, luminless, no stylet. And hopefully that gives us some keys as to this is being used as compared to more traditional ICD leads. Next we have the fontan procedure. I had to look this up because I had actually never really heard of this. So the fontan procedure is a surgical approach used for children born with certain complex congenital heart defects where they have a single functional ventricle. And if one of the ventricles doesn't form correctly, the other one has to do both jobs and it makes the heart have to work much harder. So this procedure actually reroutes blood flow so that oxygen pore blood can travel directly to the lungs and bypasses the heart. Now, historically, one of the challenges with this surgery was that the materials used to create the pathway for blood flow didn't grow with the child. So that often meant additional surgeries over time as the patient outgrew the original repair. Synthetic graft material also has a higher incidence of calcification, which actually can potentially cause late-term graft failure, and actually an increased incidence of cirrhosis due to fontan-associated liver disease, which is a leading cause of late-term morbidity and mortality for these patients as well. So when we're talking about this newer technology, the autologous cell-seeded tissue-engineered resorbable scaffold technology, it's designed to address these limitations because it's a biologic, so it can grow and hopefully remodel with the patient to form that new functioning vessel. And it also has an increased resistance to calcification. So because of advances like the Fontan procedure and improved long-term care, I just wanted to note that we are now starting to see patients, more patients surviving into adulthood. It's actually predicted the next 20 years, we can expect the population with this Fontan circulation to reach up to 150,000. And with that shift, we're seeing more adults presenting with long-term complications related to this physiology, with the most common complication being heart failure. I'll pass it back to you, Vanessa.

SPEAKER_03 24:16

Thank you. Next we have under new technology, clinical rationale for electromechanical obstetrical dilator use. So here we have a code added. This is going to be table X U7, dilation of female reproductive system, created with value one for intraluminal device, temporary electromechanical, and body part value V to be vagina, excuse me, G for vagina, was added with the approach value of seven via natural or artificial opening. And that will capture the use of the electromechanical obstetrical dilator to incrementally prepare the pelvic floor muscle for delivery. And Brittany, I will pass her back.

SPEAKER_02 25:00

Thanks. So you basically described it, Vanessa, and this is what it sounds like. It's designed to gradually and controllably stretch the vaginal tissues during labor and help prepare those pelvic floor muscles for delivery to reduce trauma during vaginal birth, particularly in patients who are delivering vaginally for the first time. And by stretching the pelvic tissues, it's aiming to lower the risk of levator ani muscle injury and avulsion. And by preventing that type of injury, it's important because that's been linked to pelvic organ prolapse later on, which can create long-term symptoms like pelvic pain and pressure, urinary and fecal incontinence, and even sexual dysfunction.

SPEAKER_03 25:39

Thank you. Next new technology here is for new therapeutic substances. So we have three substances added that are going to be alpha-1 proteinase inhibitor. We'll talk a little bit more about that. One that I just cannot pronounce, and we had a nickname for it. So that's the one in the middle, and then the sophatic stem cells. Brittany, you want to talk a little bit about what those will look like.

SPEAKER_02 26:06

Sure. So that alpha one proteinase inhibitor, it may be used in combination with corticosteroids to help reduce inflammation as well as regulate T cells in adults that are presenting with acute graft versus host disease. And it's a rare but very life-threatening condition that can occur in patients who are undergoing an allogenic hematopoietic stem cell transplant. And it's mainly going to affect their skin, liver, and GI tract, among other things. But this is a new medication, as currently, right now, standard of care or corticosteroids. Those somatic stem cells, those are undifferentiated stem cells that can self-renew and differentiate into specialized cell types to help maintain and repair tissues within their tissue of origin. So bone cells and bone marrow, skin cells and skin. And they've been used in various treatments. So things like cancers, aplastic anemia, sickle cell, certain immune conditions as well. So that middle one, I'm hoping I'm not butchering it. I think it's anidocactogene auto loose cell immunotherapy. It's named anidocell. And it's an autologous CAR T cell therapy that's designed to target these B cell maturation antigens on multiple myeloma cells. And it basically incorporates this new synthetic binder to effectively eliminate multiply myeloma cells for patients with relapsed or refractory multiple myeloma. And then Vanessa, if you want to go to the other side, just wanted to talk about that real quick. So one of the potential but very serious side effects of CAR T cell therapy is cytokine release syndrome or CRS. And it's a potentially life-threatening complication that's driven by this massive cytokine release, causing an acute systemic inflammatory response. And what these phase one trials are seeing is that this medication has a safer profile and it's a more effective treatment compared to other CAR T cells. They're also finding in this study that the majority of patients, if they had CRS, it was more mild in nature. They were usually only presenting with a fever and it was much more manageable. Now, from a clinical perspective, CRS can also overlap SERS. So we do want to be mindful and looking: is there specific documentation about this excessive cytokine release? Are they on CART T cell? Typically, the fever has to be there. Typically, it presents five days afterwards. But just looking for those types of things and then certainly querying if it's not clear. Additionally, that anito cell in the phase one trial found no delayed cases of neurotoxicities in those phase one trials. So no Parkinsonisms, no cranial nerve palsies, no Guillaume-Barre syndrome, and no immune effector cell associated enacolitis, which we can see with other CAR T cell therapies. So really the most common complication we're seeing in these patients is cytopenias.

SPEAKER_01 28:55

Thank you, but Brittany, I'm going to jump in really quick, Vanessa. Can you hear me? In the last four weeks, we have had four clients ask questions about this particular coding clinic as well as the CRS and the SERS. So we need to make sure that when we're issuing queries and towers or doing reviews, that we are not only aware of it, but really dotting our I's and crossing our T's.

Final Takeaways And How To Reach Us

SPEAKER_00 29:18

At Acuity, we're transforming healthcare reimbursement with a provider-driven, innovative approach. We share valuable clinical and coding insights and current best practices to improve financial outcomes across health systems. If you have any questions or would like to offer a topic to discuss, please email info at acuityhealthcare.com. Opinions expressed in this production are those of the host or guests and do not represent official stances of acuity. The suggestions, advice, and guidance provided by the individuals featured in this podcast are not intended to replace any medical advice, consultation, or treatment you may receive from your healthcare provider.