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Download the article PDF: Icd 10 Changes Impacting Urgent Care
Tricia Krueger, CPC, is RCM Coding Supervisor for Experity.
ICD-10 has been ever changing since it was first adopted 10 years ago. Each year, the Centers for Medicare & Medicaid Services (CMS) revise, add, and delete diagnoses to better suit the conditions, including the conditions that present in urgent care centers. These changes reflect advances in clinical understanding and the need for more precise documentation in fast-paced care settings.
While ICD-10 changes can happen semi-annually, most changes happen in October. For the upcoming 2025-2026 update, there are 487 new codes, 38 code revisions, and 28 deleted codes, all of which will take effect October 1, 2025. This update includes several additions that will impact urgent care specifically. To stay ahead of these changes, it is important to be prepared. Centers that are trained and ready will experience smoother claim submissions and fewer rejections.
1. Pain‑and Tenderness Codes
The old “pelvic and perineal pain” code (R10.2) has been replaced with multiple newer, more detailed codes specifying site and laterality. Providers must now capture laterality and exact pain location in the clinical note for proper coding.
- R10.20 – Pelvic and perineal pain, unspecified side
- R10.21 – Pelvic and perineal pain, right side
- R10.22 – Pelvic and perineal pain, left side
- R10.23 – Pelvic and perineal pain, bilateral
- R10.24 – Suprapubic pain (subpubic region)
2. Laterality For Eyelid Inflammation
The single code H01.8 for eyelid inflammation is being eliminated. In its place are 9 distinct codes differentiating upper vs. lower eyelid and right vs. left eye. Clear documentation from clinicians about eyelid site will be essential.
- H01.81 – Other specified inflammation of right upper eyelid
- H01.82 – Other specified inflammation of right lower eyelid
- H01.83 – Other inflammation of right eye, unspecified eyelid
- H01.84 – Other specified inflammation of left upper eyelid
- H01.85 – Other specified inflammation of left lower eyelid
- H01.86 – Other specified inflammation of left eye, unspecified eyelid
- H01.89 – Other specified inflammation of unspecified eye, unspecified eyelid
- H01.8A – Other specified inflammation of right eye, upper and lower eyelids
- H01.8B – Other specified inflammation of left eye, upper and lower eyelids
3. New Allergy Codes
Urgent care clinics occasionally see presentations concerning food allergies. The 2026 coding update introduces many new codes for adverse reactions and anaphylactic responses to foods such as eggs and milk/dairy.
Eggs
The update includes several new codes related to eggs, including codes to capture adverse reactions, anaphylactic reactions, and allergies to eggs. Here are just a few examples:
- T78.120A – Other adverse food reaction due to egg with tolerance to baked egg, initial encounter
- T78.129A – Other adverse food reaction due to egg with baked egg tolerance/reactivity, unspecified, initial encounter
- T78.080A – Anaphylactic reaction due to egg with tolerance to baked egg, initial encounter
- T78.081A – Anaphylactic reaction due to egg with reactivity to baked egg, initial encounter
- T78.089A – Anaphylactic reaction due to eggs, unspecified, initial encounter
- Z91.0120 – Allergy to eggs, unspecified
Milk and Dairy Products
Like eggs, the update also includes several new codes related to milk and dairy products, including new codes related to adverse reactions, anaphylaxis and allergies. Some examples are:
- T78.110A – Other adverse food reactions due to milk and dairy products with tolerance to baked milk, initial encounter
- T78.111A – Other adverse food reaction due to milk and dairy products with reactivity to baked milk, initial encounter
- T78.119A – Other adverse food reaction due to milk and dairy products with baked milk tolerance/reactivity, unspecified, initial encounter
- T78.070A – Anaphylactic reaction due to milk and dairy products with tolerance to baked milk, initial encounter
- T78.071A – Anaphylactic reaction due to milk and dairy products with reactivity to baked milk, initial encounter
- T78.079A – Anaphylactic reaction due to milk and dairy products, unspecified, initial encounter
- Z91.0110 – Allergy to milk products, unspecified
ICD 10 Denial Trends in Urgent Cares
When documenting visits, it is always important to be as specific as possible. Each year, we see an increase in denials for unspecified codes. Insurance companies will not reimburse a service such as an x-ray, for example, if the laterality is unspecified. Providers need to keep this in mind when it comes to selecting the proper codes.
- Code Specificity: Always select the most specific and appropriate code based on documentation.
- Combination Coding: Recognize instances where multiple codes are required, such as complications or associated conditions.
- Documentation Quality: Ensure clinical staff document with precise detail, clearly indicating anatomical sites, severity, and associated health conditions.
Another common denial can occur with ancillary tests. We have found that payers do not want a definitive diagnosis for testing. Instead, payers want to see the symptoms the patient presented with that led to the decision to test. For example, a patient presents with fever, cough, and a sore throat. The provider orders an influenza A&B test and a strep test. The patient tests positive for influenza B, so the patient is thus diagnosed. Providers also need to diagnose the patient with fever, cough, and sore throat to ensure those ancillary tests are properly paid.
When it comes to changes and new ICD-10 codes, education is key. Providers should be aware of updates in advance and continue to practice documentation skills. Doing so will not only keep the center compliant but will also increase the chances of billing clean claims.
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