Recorded at HEALTHCON 2024 in Las Vegas, NV

Join AAPC experts for a deep dive into 2025 ICD-10-CM updates, clinical documentation debates, and real-world coding dilemmas. From “with” guidelines to tamoxifen therapy, BMI logic, OIG audits, and social determinants of health, this session brings clarity, context, and actionable insight for coders, CDI professionals, and compliance leaders.

Linking diagnoses: When “with” lets you connect conditions

• Use the index and guideline “with” convention to connect terms that are linked in ICD-10-CM (for example, “herniated disc with radiculopathy”) when the index explicitly supports it.

• Don’t over-infer for complications or post-op issues; confirm causality in documentation when “with” isn’t supported in the index.

Post-op pain versus complication: Proceed with caution

• Expect some pain after surgery and avoid defaulting to complication codes without documented causal language from the provider.

• For revision surgeons evaluating persistent pain years after joint replacement, push for specificity: device reaction, malposition, loosening, wear, or other mechanical failure.

Tamoxifen after cancer: Active treatment versus history

• Treat adjuvant endocrine therapy as part of the active treatment plan when documented as such (for example, within the plan of care).

• Use personal history status when there is no evidence of disease and no active treatment; rely on clear provider statements rather than assumptions about duration.

BMI and normal BMI z codes: When and why to report

• Coding Clinic guidance requires BMI to be clinically relevant to a documented condition, not just listed as a number.

• Normal BMI z codes can be appropriate when weight status is being actively managed or tracked for a related condition or care plan, not only for obesity.

• Remind teams that coders don’t interpret values; providers must link BMI to the clinical picture.

Ortho revision documentation: Make the “why” obvious

• Educate providers that “knee pain” alone won’t support revision; document the mechanical or biological reason for failure where known.

• Align booking, orders, and op notes so the indication (for example, “herniated disc with radiculopathy”) carries forward consistently.

Guidelines versus clinical reality: Who should adapt and how to push change

• When guidelines lag practice, escalate: request payer clarification, contact your MAC, and submit questions to Coding Clinic for formal guidance.

• Don’t “suffer in silence”; bring repeat problem patterns with examples to the bodies that can update or clarify.

OIG and payer audits on diagnosis codes: Expect stricter edits

• Expect denials where categories have seen abuse (for example, acute stroke in risk adjustment without robust support).

• RADV extrapolation back to 2018 raises the stakes for health plans and provider groups; tighten documentation now.

• Use provider education and outpatient CDI to move capture closer to the point of care and reduce retrospective corrections.

2025 ICD-10-CM updates (October): Highlight reel

• Guideline refinements to sequencing for sepsis in pregnancy, reminders to list chemotherapy or radiotherapy first when that is the encounter purpose, updated language on breast implant–associated anaplastic large-cell lymphoma, presymptomatic type 1 diabetes guidance, and expanded receptor-status descriptors (estrogen, progesterone, other hormone).

• Infectious disease updates include corrected inclusion terms for Clostridioides difficile.

• Hematology/oncology adds remission status characters for Hodgkin lymphoma and a new anemia code affecting bone marrow (d61.03).

• Endocrine/metabolism adds presymptomatic diabetes (e10.a), hypoglycemia level detail, carcinoid syndrome options, and new obesity codes including pediatric BMI and etiologies such as mc4r pathway disruption and citrate metabolism disorders.

• Mental and behavioral health expands eating-disorder coding (f50-) including anorexia, bulimia, and adult pica.

• Neurology adds g40.84 for a specific epilepsy type with child codes for intractability/status, plus codes for other autonomic and developmental epileptic encephalopathies.

• Ophthalmology revises degenerative myopia language to remove forced bilaterality where inappropriate.

• Circulatory system adds embolism detail (cement, fat) with and without acute cor pulmonale and clarifies “thrombotic” language.

• Respiratory adds nasal valve collapse with internal/external and static/dynamic detail.

• Digestive system expands anal fistula complexity (simple versus complex) and course (initial, persistent, recurrent).

• Dermatology introduces pruritus detail and descriptor refinements across several conditions.

• Musculoskeletal disc disorders now let you specify pain location (for example, “with lower extremity pain only”) and add synovitis/tenosynovitis options.

• Congenital adds q23.8 for aortic/mitral malformations.

• Symptoms and signs add r41.85.

• Injury/poisoning adds checkpoint-inhibitor poisoning, revises t81.32 for internal wound disruption, and reminds teams to use underdosing where appropriate.

• Factors influencing health status add z15.1 for genetic susceptibility to epilepsy/neurodevelopmental disorders, a new encounter for sepsis aftercare (z51.a), duffy antigen detail, and family history of polyps.

• Social determinants of health expands welfare/support coding; inpatient SDOH can affect DRG as of 2024, and outpatient quality measures will track SDOH beginning in 2026 using 2025 data.

Behavioral health unspecified codes: Why denials are rising

• DSM-5-TR uses “unspecified” when the clinician declines to be more specific, which is narrower than ICD-10-CM’s notion of “unspecified.”

• Short stays and initial assessments may warrant unspecified, but longitudinal care should move to specific diagnoses as the clinical picture clarifies.

• Some denials are tech-driven edits; audit your payer and internal edits to prevent blanket rejections of valid unspecified codes while still pushing specificity in documentation.

Imaging orders and “payable code” myths: Use LCDs/NCDs and fix workflows

• Replace “payable code” talk with “meets medical necessity under LCD/NCD or policy.”

• Build front-end workflows: give schedulers LCD/NCD lists, add EMR prompts, and set ABN rules so indications and coverage are verified before scheduling.

• When a payer demands sequencing that conflicts with guidelines, get it in writing via policy or contract amendment and escalate through contracting if needed.

ASC gi example: Heartburn versus gerd on EGD

• If the op note only documents “heartburn,” don’t upgrade to gerd without support; query the physician for definitive findings.

• Coordinate with referring offices so the indication on the booking form matches the physician’s documented pre-procedure assessment and the op report.

Code-first notes and payer contradictions: What to do

Follow coding guidelines first; if a payer systematically denies guideline-compliant sequencing, escalate to your payer’s contracting or legal channel with examples and request policy correction in writing.

SDOH: Why, how, and when to code

• Code SDOH when they affect care, treatment, or management at that encounter, and ensure provider validation of patient-reported information.

• Avoid blanket carry-forward; update when resolved (for example, housing secured).

• Remember there is a physician-side g-code for assessing and addressing SDOH, and inpatient SDOH may change DRG assignment.

• “Lives alone” is not a problem by itself; document the actual barrier (for example, inability to perform ADLs without support).

Dexa scans: Screening versus established condition

• Don’t pair a screening code with a confirmed condition on the same claim; use screening when screening, and use the condition (for example, osteoporosis) when known.

• For surveillance of known disease, report the disease, not a screening z code.

Observation “ruled out” encounters

Encounter for observation of suspected conditions ruled out can be a valid principal diagnosis when it meets reporting criteria for the setting and payer.

No LCD doesn’t mean no payment

An LCD is a MAC’s clarifier, not a prerequisite for coverage; in the absence of an LCD, lean on national policy and documented medical necessity.

Fractures and seventh characters: Keep problem lists honest

Audit active problem lists to ensure initial/continued care “a/d/s” characters reflect current status and don’t linger year over year for risk adjustment or billing.

Abortion clinic SDOH documentation: How much is enough

• One patient statement can establish an SDOH, but the provider should validate and note how it affects today’s care plan.

• For genetics, ask patients to supply reports or source documentation and record how results inform management.

Provider word-choice sensitivities: Be accurate and respectful

• Terms like “morbid obesity” and “severe heart failure” are clinical and should be used when true; prepare clinicians to discuss them transparently with patients who can view their records.

• Avoid pejorative language; stick to clinical facts and patient-centered explanations.

Clinical trials and documentation honesty

• Document adverse effects and severity accurately for E/M medical decision making even when a study sponsor will review records; patient safety and truthful records come first.

• Clarify what PHI is shared with sponsors and maintain separate blinded documentation as required by the protocol.

Cardiology consults and unrelated history

• Don’t load unrelated historical procedures or conditions into the cardiology encounter unless they are clinically relevant to today’s evaluation or management.

• If edema is documented, clarify etiology (for example, cardiac versus post-surgical) before coding.

Epidural example: Align indications across the timeline

• Ensure the condition that justified the procedure (for example, “herniated disc with radiculopathy”) is carried forward consistently from H&P to order to operative documentation.

• If the op note only says “radiculitis” but prior notes support a more specific linked diagnosis, query to align and support LCD requirements.

Practical takeaways

• Teach to the index and guidelines, and query for causality rather than assume it when “with” doesn’t apply.

• Move diagnosis capture closer to the point of care with outpatient CDI and clear provider education.

• Harden workflows around LCD/NCD coverage, ABNs, and payer-specific quirks captured in writing.

• Treat SDOH as part of medical necessity and quality reporting, documenting impact and actions taken.

• Track 2025 code changes that affect risk adjustment and DRGs, and update templates and provider education accordingly.