Note from the CDI Education and HIM/Coding Directors: Spring is in the air…and so is AHA Coding Clinic First Quarter 2025!

by Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, and Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, CCDS-O

With spring comes rain, flowers, singing birds, new life and the year’s first edition of American Hospital Association’s (AHA) Coding Clinic. First quarter 2025 AHA Coding Clinic is blooming with excitement, so let’s review some of the significant changes.

We start off with a notable change in the Official Guidelines for Coding and Reporting related to COVID-19: Guidance that code assignment be based merely on a positive COVID-19 result has been removed. It is instead based on provider documentation. In addition, asymptomatic patients who test positive with no documented COVID-19 diagnosis require a query be sent to the provider, as false positives do occur.

We have all been patiently waiting for further clarification on obesity classification coding changes (e.g., when we have morbid obesity and class 3 obesity, which one is to be reported?). Luckily, the guidelines provide some clarification here: If both class 3 obesity and morbid obesity are documented, only code class 3, as it is more specific. Remember: Class 3 obesity may also be categorized as severe obesity.

Coding and reporting have also had some interesting things spring up (no pun intended!). Within infectious disease, a code for streptococcus viridans bacteremia is not reported separately from endocarditis of a transplanted aortic valve: the bacteremia is considered symptomatic and inherent. The coding would be a complication code of T82.6XXA for the infected cardiac valve prosthesis and then I33.0 for acute infective endocarditis and organism code B95.4 for other streptococcus.

Some interesting endocrine guidance relates to a diabetic patient with venous stasis ulcer due to venous insufficiency. In this case, the assumption cannot be made that the venous insufficiency is related to diabetes based upon the documentation. The correct assignment would be I87.2, Venous insufficiency; a code from category L97 for the non-pressure chronic ulcer based on location, and a diabetes code by type without complications unless other conditions existed or were queried for.

From a cardiovascular standpoint, there are two coding updates. When you have cardiac valves with conditions of disease, we must take precautions not to combine those conditions into a multiple valve disease code. A patient with endocarditis and stenosis of the aortic valve prosthesis also has mitral valve regurgitation. This does not equate to a code for multiple valve disease but should be coded as a complication of the valve prosthesis (T82.6XXA) with I33.0, Acute and subacute infective endocarditis; T82.857A, Stenosis of other cardiac prosthetic devices, implants and grafts, initial encounter (for stenosis of aortic valve); and I34.0, Nonrheumatic mitral (valve) insufficiency (regurgitation). 

Another cardiovascular update involves a patient with a known coronary artery disease and a history of coronary stents. The case is as follows: the patient was admitted for a non-ST-elevation myocardial infarction (NSTEMI) and taken for a heart catheterization procedure. Findings included multi-vessel coronary artery disease (CAD). Stent occlusions with neoatherosclerosis were present, and a balloon angioplasty intervention was performed. 

How would the NSTEMI due to neoatherosclerosis of a stent be reported? In this particular case, I21.4, NSTEMI, is the principal diagnosis followed by the T82.855A, Stenosis of coronary artery stent, initial encounter, and a code from category I25 for the CAD. 

(With respect to the sequencing suggested in this guidance, readers may also want to reference previous Coding Clinic guidance from AHA Coding Clinic, Third Quarter2021.)

The Coding Clinic also discusses acute kidney injury (AKI) and its relation to hepatorenal syndrome (HRS), a specific type of AKI. Although it is not as common, it is important to capture HRS, as it is an MCC. It develops from a precipitating event and is more common in cirrhosis and ascites patients. When both conditions are present, both are coded. Assign N17.8, Other acute kidney failure, to indicate that the type of AKI is HRS, along with K76.7, Hepatorenal syndrome. The Excludes2 note permits reporting of both codes. 

Obstetrics and newborn changes

For those of you reviewing obstetrics charts, a patient with a Bartholin’s abscess drained during delivery will receive an obstetric code and not a code from the inflammatory diseases of pelvic organs category (N70-N77) due to the Excludes 1 note. It would also not include O75.3, Other infection during labor. In this case, it would be coded to O23.59-, Infection of other part of genital tract in pregnancy, and would be based on trimester.

Newborn coding also includes two aspects we need to be aware of. When you have a newborn that was delivered breech and now, six weeks later, has an ultrasound of the hip study performed, do you assign the code P01.7, Newborn affected by malpresentation (breech) before labor? In this case you would, per UHDDS guidelines that a “condition is clinically significant if it [...] has implications for future health needs.”

In addition, if a premature newborn has been diagnosed with prematurity and jaundice and receives phototherapy with monitoring of bilirubin levels, the correct assignment is P59.0 for the neonatal jaundice associated with premature delivery since it is an assumed relationship, according to Coding Clinic.

Another diagnosis code and condition to understand is the “Cyclops" lesion post anterior cruciate ligament (ACL) repair. This lesion is known as a localized anterior arthrofibrosis and is classified to ankylosis. It occurs as a complication of ACL reconstruction and therefore is coded as complication code: T84.82X-, Fibrosis due to internal orthopedic prosthetic devices, implants, and grafts, with M24.66-, ankylosis, knee, with laterality to be specified.

PCS changes

Now on to our procedural coding system (PCS) changes. As of April 1, 2025, there are 50 new ICD-10-PCS codes. While the full list can be found here, we’ve highlighted some important ones below.

There are two codes related to the trachea. The first is an endoscopic tracheoesophageal puncture (TEP). This procedure is performed to restore the patient’s ability to speak after vocal cords have been removed (total laryngectomy) and a voice prosthesis is then inserted to allow esophageal speech to occur.

The procedure is considered a bypass and the code character for the approach, 8 (via natural or artificial opening endoscopic), has been added for this procedure. The second procedure entails adding an open approach for a transplantation of the larynx. The transplant can be either allogeneic or syngeneic, as distinguished by the qualifier.

With gynecological procedures, the advancement of surgery provides surgical options for vaginal reconstruction utilizing the ileum. The 0DX- PCS table maps the body part of the small intestine via open or percutaneous endoscopic approach with the qualifier or transferred site being the vagina. These procedures can be performed for various reasons including congenital vaginal atresia, trauma, cancer or plastic surgery reconstruction.

The obstetrical procedure for labor induction via mechanical cervical ripening (0U7-) can employ many methods; however, in this case, laminaria sticks are used to soften and “dilate” the cervix; therefore, their usage would be considered a dilation procedure. By contrast, other agents, such as Cervidil® or Cytotec® are coded under the root operation of introduction, as they are ripening agents.

With cesarean section deliveries, we also have a new approach of 0 under our extraction of retained products of conception (POC) using code 10D- when the extraction is performed during a c-section.

The Coding Clinic also includes additions to the orthopedic administration codes for open joint procedures, in particular fusions/bone grafting. This new substance has been utilized as new technology since 2020. The augment bone graft is used for ankle and foot surgeries and contains both growth factor (rhPDGF-BB) and synthetic bone matrix. Due to the fact that the service is an injection procedure, it is assigned to the administration PCS category as an “introduction of other substances” in joints. The qualifier is C for other substance.

Additional updates and procedures for new technologies include the following:

• Cardiac stereotactic body radiotherapy (SBRT) with code D22- is for patients with refractory ventricular tachycardia. This option permits precise delivery of radiotherapy while minimizing damage.
• Transcatheter bypass of left atrium to right atrium via coronary sinus is a permanent shunt treatment for heart failure patients to relieve the pressure caused by weakened left ventricles creating left atrial back up. The body part is the left atrium with the device value serving as a conduit through the coronary sinus to the right atrium.
• Insertion of heterotopic bicaval valves (X2U-) is utilized as a prosthetic treatment for tricuspid regurgitation. These self-expanding biological valves protrude fully into the right atrium and therefore fall into the body part of right atrium via percutaneous femoral approach and are bicaval due to inferior vena cava (IVC) and superior vena cava (SVC) placement. Note: This advice supersedes those provided in AHA Coding Clinic, Fourth Quarter 2023.
• The administration of two new oncology agents includes emapalumab-Izsg, which is an interferon gamma-blocking antibody in the treatment of hemophagocytic lymphohistiosis (HLH), and tarlatamab-dlle, which is a T-cell engager used in the treatment of advanced small cell lung cancer.
• An new testing capability for sepsis has been added, IntelliSep. This test is used in places like the emergency department to triage for early detection of sepsis. The test measures the properties of various individual leukocytes, is quickly read within eight minutes, and can help risk-stratify those patients with potential sepsis.
• While there were no updates to the ICD-10-PCS coding guidelines this quarter, 12 codes were deleted from the 0SG- Fusion, Lower Joints table for the coccygeal joint, as they are clinically invalid.
• Lastly, there are two final clarifications related to surgical procedures. The Mazor™ Stealth Robot is a computer-assisted navigation device for the correct placement of pedicle screws. The correct code assignment would be 8E0W0CZ, Robotic assisted procedure of trunk region, open approach. Another clarification relates to the subacromial balloon spacers in the arthroscopic placements. These are meant to dissolve within a year and are utilized for cushioning of the joint during healing. The correct code falls under supplement and then right or left shoulder bursa and ligament, open percutaneous approach. The device is a synthetic substitute.

And there you have it! We are off to a great start in staying up to date on the latest guidance, so please share this information with your teams, discuss the nuances in your organizations, and spring into action!

Editor’s note: Wilk is the CDI education director at ACDIS/HCPro. Contact her at deanne.wilk@hcpro.com. McCall is the director of HIM/Coding at HCPro. Contact her at Shannon.mccall@hcpro.com.