ICD 10 changes impacting Urgent Care in 2025 

ICD10 has been ever changing since it was first adopted ten years ago. Each year the Centers for Medicare & Medicaid Services (CMS) revise, add and delete diagnosis to better suit the conditions including those affected by 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 we find 487 new codes, 38 code revisions, and 28 deleted codes. This will take affect October 1, 2025, and run through September 30, 2026. 

Urgent care clinics frequently see conditions such as respiratory infections, injuries, and acute illness. The 2026 ICD-10 update includes several additions that will impact urgent care: 

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) 

Laterality for Eyelid Inflammation

The single code H01.8 for eyelid inflammation is being eliminated. In its place are nine 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 

New Allergy Codes

Urgent care clinics often see allergic reactions. The 2026 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: 

1. T78.120A, Other adverse food reaction due to egg with tolerance to baked egg, initial encounter 
2. T78.129A, Other adverse food reaction due to egg with baked egg tolerance/reactivity, unspecified, initial encounter 
3. T78.080A, Anaphylactic reaction due to egg with tolerance to baked egg, initial encounter     
4. T78.081A, Anaphylactic reaction due to egg with reactivity to baked egg, initial encounter 
5. T78.089A, Anaphylactic reaction due to eggs, unspecified, initial encounter 
6. 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: 

1. T78.110A, Other adverse food reactions due to milk and dairy products with tolerance to baked milk, initial encounter 
2. T78.111A, Other adverse food reaction due to milk and dairy products with reactivity to baked milk, initial encounter 
3. T78.119A, Other adverse food reaction due to milk and dairy products with baked milk tolerance/reactivity, unspecified, initial encounter 
4. T78.070A, Anaphylactic reaction due to milk and dairy products with tolerance to baked milk, initial encounter 
5. T78.071A, Anaphylactic reaction due to milk and dairy products with reactivity to baked milk, initial encounter 
6. T78.079A, Anaphylactic reaction due to milk and dairy products, unspecified, initial encounter 
7. Z91.0110, Allergy to milk products, unspecified 

To stay ahead of these changes, it is important to be prepared. Clinics that are trained and ready will find claim submissions will be smoother and will have less rejections.    

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 such as laterality. Insurance companies will not reimburse a service such as an x-ray if the laterality is unspecified. Providers need to keep this in mind when it comes to selecting the proper diagnosis. 

Keep in mind these critical guidelines: 

• 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 is regarding ancillary tests.  We have found that payers do not want a definitive diagnosis for testing. Payers want to see the symptoms the patient presented with that lead 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 that is how the patient is diagnosed. Providers also need to diagnose the patient with fever, cough and sore throat to get those ancillary tests paid. 

When it comes to changes whether it be new ICD10 codes or denials, continuing education is key.  Providers should be aware of what is to come and continue to practice documentation skills. Doing so will not only keep you compliant but will also increase your chances of billing a clean claim. Remember to prepare providers and staff for next October when more changes come.