By Leigh Poland, RHIA, CCS, CDIP, CIC, is Vice President – Coding Services, Clinical Quality, and Education, AGS Health
The latest ICD-10 update may look insignificant to many healthcare organizations. There are no sweeping diagnosis code additions, no major guideline rewrites, and no dramatic restructuring of the classification system at first glance.
That perception could become a costly mistake.
The April 2026 ICD-10 changes introduced by the Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) are deceptively quiet. While the diagnosis code set itself remains largely untouched, the update alters something far more consequential: the decision-making framework coders use to determine sequencing, coexistence, and classification relationships. In practical terms, the update shifts more responsibility onto coder judgment, documentation precision, and organizational oversight.
For health systems already navigating staffing shortages, denials pressure, increasing payer scrutiny, and growing dependence on encoder technology, even modest classification logic changes can create operational instability.
The Real Change Is Not the Codes
The 2026 ICD-10-CM release includes no additions, deletions, or revisions to diagnosis codes. The Official Coding Guidelines also remain unchanged. But focusing only on code counts overlooks where the actual disruption is occurring.
The most meaningful changes involve instructional notes, exclusions, and indexing logic embedded within the classification system itself. These structural revisions alter how diagnoses relate to one another and how coders determine sequencing priorities.
Historically, ICD-10 relied heavily on embedded hierarchy through directives such as “code first” and “use additional code.” Those instructions created relatively rigid sequencing expectations. The April update softens several of those relationships by replacing them with “code also.”
That wording change appears minor. Operationally, it is not.
“Code also” removes automatic sequencing hierarchy and places greater emphasis on the clinical circumstances of the encounter. As a result, two experienced coders reviewing similar documentation may now reasonably arrive at different sequencing conclusions.
That variability introduces downstream risk for MS-DRG assignment, reimbursement consistency, quality reporting, and audit exposure.
Hypertensive Emergency Becomes a Judgment Call
One of the clearest examples appears in category I16.1 for hypertensive emergency.
Previous instructional language reinforced sequencing expectations around the hypertensive crisis itself. Under the revised structure, coders must now determine whether the hypertensive emergency or the associated complication represents the principal reason for admission.
In real-world inpatient settings, that distinction can materially alter reimbursement outcomes.
If the case emphasis shifts toward complications such as acute kidney injury, myocardial infarction, encephalopathy, heart failure, or cerebral infarction, the resulting DRG assignment may change significantly.
What was previously more standardized now becomes more interpretive.
For revenue integrity teams, this creates a new challenge: ensuring consistent organizational logic across coding staff, CDI specialists, and auditing functions.
Expanded Coding Combinations Increase Complexity
Another major change involves the conversion of multiple Excludes1 notes to Excludes2 notes. Within ICD-10 methodology, this distinction matters enormously.
Excludes1 notes prohibit reporting two conditions together because they are considered mutually exclusive. Excludes2 notes acknowledge that conditions may coexist when clinically appropriate.
The April revisions expand the number of valid diagnosis combinations across several clinical areas, including hematologic disorders, respiratory failure, and substance-related conditions.
That expansion creates both opportunity and risk.
On one hand, organizations may now capture clinical complexity more accurately. On the other, newly permissible combinations may attract increased payer attention if documentation does not clearly establish coexistence and medical necessity.
Respiratory failure coding illustrates the issue well.
The revision affecting postprocedural respiratory failure now allows certain respiratory failure conditions to be reported concurrently when documentation supports both diagnoses. Depending on sequencing and present-on-admission indicators, these changes can influence CC/MCC assignment and case severity calculations.
Increased flexibility sounds beneficial until organizations realize it also increases variation.
Technology Alone Will Not Solve This
Many organizations assume encoder systems will absorb these changes automatically. That assumption deserves caution. Encoder logic can support compliance, but it cannot fully resolve interpretive ambiguity introduced by structural classification changes. When sequencing hierarchy is loosened, technology becomes more dependent on human documentation quality and coder judgment.
This is particularly important as hospitals continue expanding the use of AI-assisted coding workflows.
Automation performs best in environments with stable and predictable rules. The more classification systems rely on nuance, contextual interpretation, and clinical prioritization, the more critical human oversight becomes.
The April ICD-10 update quietly reinforces that reality.
Healthcare organizations increasingly pursuing autonomous coding strategies may find that classification logic changes expose gaps in governance, validation, and audit readiness.
While the diagnosis side of the update focuses on logic restructuring, ICD-10-PCS continues expanding to capture emerging procedural complexity. New codes support advancements in cardiac pacing technologies, including conduction system pacing techniques involving ventricular septal lead placement.
Additional updates improve specificity for hepatobiliary and pancreatic drainage procedures by distinguishing transpapillary and transmural approaches commonly used in advanced endoscopy.
The update also expands reporting capabilities for reconstructive urologic procedures, rehabilitation therapies, electrotherapeutic modalities, and new technology interventions involving biologics, vascular scaffolds, gene therapies, and immunotherapies.
These additions reflect a continuing challenge for healthcare organizations: clinical innovation is moving faster than many operational infrastructures can adapt.
The significance of this update extends beyond HIM and coding operations. Sequencing variability influences reimbursement predictability. Documentation inconsistency affects denial vulnerability. Coding interpretation impacts publicly reported quality measures and risk adjustment performance.
In other words, structural coding logic changes eventually become enterprise financial and operational issues.
Organizations that dismiss this release because it lacks major code volume changes may underestimate its cumulative effect over time.
The healthcare industry often focuses attention on large regulatory overhauls while overlooking smaller classification refinements that quietly reshape operational behavior. This update falls squarely into that category.
The Organizations Most Likely to Struggle
The greatest risk may not come from the coding changes themselves but from uneven organizational response.
Health systems with mature auditing programs, strong CDI integration, and consistent coding governance will likely adapt relatively quickly.
Organizations with fragmented workflows, inconsistent education practices, or overreliance on automated coding recommendations may experience wider variability in coding outcomes.
The most immediate priorities should include:
Focused auditing of high-variability categories, such as hypertensive emergency and secondary glaucoma
Education around newly permissible diagnosis combinations
Validation of encoder and grouper functionality
Alignment between coding, CDI, compliance, and revenue integrity teams
Increased review of documentation sufficiency for concurrent condition reporting
The danger is not a dramatic overnight disruption. It is the gradual accumulation of inconsistencies across thousands of encounters.
A Quiet Update With Long-Term Consequences
The April 2026 ICD-10 revision is a reminder that healthcare reimbursement systems do not need sweeping reform to create operational consequences.
Sometimes the most impactful changes are the least visible.
By loosening embedded sequencing hierarchy, expanding allowable diagnosis relationships, and increasing procedural specificity, the update subtly changes how coding decisions are made across the enterprise.
That shift places greater pressure on judgment, governance, and the integrity of documentation at a time when healthcare organizations are already balancing financial strain and operational complexity. The organizations that recognize the significance early will be better positioned to maintain coding consistency, compliance stability, and reimbursement accuracy.
Those who treat this as a routine update may discover the real impact only after denials, audits, and DRG variation begin to surface.
By Catherine O’Leary, RN, managing director, healthcare advisory/CDI, KPMG.
Catherine O’Leary
COVID-19 is imposing a humanitarian and economic toll around the world, and healthcare providers are on the front lines of the response. New COVID-19 medical codes that went into effect on April 1 have an important part in clinical decision making, disease surveillance, population health management and research on the pandemic.
The new codes allow healthcare officials, clinicians, and researchers to capture claims data and use the information to better inform a course of action tied to COVID-19, whether that is for setting aside more beds, creating special units to handle the highly contagious viral infection, routing ambulances to facilities that can handle the emergency or other responses.
Because of the evolving situation, codes are rapidly changing. With every coding update, it is vital for everyone involved in the reporting of claims data, such as coding professionals, clinical documentation improvement specialists, healthcare IT professionals and coding auditors to respond to the changes.
All COVID-19 confirmed cases, documentation of a positive COVID-19 result, or a presumptive positive COVID-19 test result should be coded as U07.1, COVID-19. As a general rule, it is still imperative to follow the Official Coding Guidelines in the selection of principal or first-listed diagnosis (i.e., sepsis, obstetrics, etc.). Furthermore, it is important to report the other conditions/co-morbidities to present the overall severity and risk of mortality of a patient. If a patient presents with signs and symptoms with no definitive diagnosis, there are codes available to capture the reason for the encounter.
This is the guidance that we’re receiving on telehealth:
Services provided do not need to be COVID-19 related and can be offered in all settings, including a patient’s home.
Payers will not enforce the requirement that patients will have an existing relationship with the physician (clinician?) providing telehealth.
Physicians in one state may provide services to patients in another state, but state licensure applies.
Providers will be reimbursed at the same rates as if the service was provided in person.
Telehealth claims should properly reflect the place of service code (02-Telehealth).
With the coding guidance from CDC, the onus is still on healthcare providers to stay informed about the current regulations, as well as potential changes to ensure that COVID-19 encounters are recorded appropriately. Also, the data gathering helps with clinical decision making for quality patient care, disease surveillance, population health management, research and regulatory mandates.
The AHIMA Foundation is expanding its registered apprenticeship program to include an inpatient coding auditor role based on recent employer feedback. Registered apprenticeship, a proven strategy, ensures quality workforce readiness training by combining on-the-job learning with hands-on instruction to prepare exceptional workers for American industry.
The process of apprenticeship program registration is designed to ensure that working apprentices, program employers and the public can gain a clear understanding of the training content and that measures that are in place to ensure ongoing quality.
The increase in regulatory audits, downgrading MS-DRGs under ICD-10 and an increase in denials are drivers of impacting the growing need for this role. In-patient coding auditors bring knowledge of code validation and accurate MS-DRG assignment, classification of coding and denial issues and the ability to analyze audit results in order to track and trend overall improvement and resolution. Employers can now choose inpatient coding auditor from the six available roles helping to build a stronger and more experienced health information workforce.
“Our new Inpatient Coding Auditor role will help our apprentice increase the revenue and improved data quality of their employers because nothing will be misplaced or delayed,” said Keith D. Terry, interim executive director of the AHIMA Foundation.
Now is the time for organizations to join the AHIMA Foundation program to expand apprenticeships in healthcare and meet their talent needs and to stay competitive. The registered apprenticeship program can be an effective component of an employer’s staffing strategy and a talent development pathway for workers to gain additional skills and credentials. The AHIMA Foundation offers a free webinar for those wanting to learn more.
The AHIMA Foundation is completing year four of the five-year American Apprenticeship Initiative grant from the US Department of Labor (DOL) to support the expansion of registered apprenticeship programs into career pathways to meet employer needs, particularly into new fields like health information management. The AHIMA Foundation has been working with the DOL Office of Apprenticeship in addition to state apprenticeship agencies to help employers work through the process of creating and sustaining their registered apprenticeship programs.
From last few years, there have been significant modifications in the rules in addition to guidelines that medical coding and billing firms must achieve. The medical billing vendor that is fully compliant in all under HIPAA are authoritatively business associates of most ideal healthcare clients. This means they never reveal private information, take substantial deterrents with client data, and shield the uprightness of the client.
But another utmost and instantaneous requirement is to influence the company’s profits as to make certain you file the medical claims as rapidly and swiftly as possible. For this determination, you can farm out the situation to a medical billing vendor as they promise to adhere to a strict round-the-clock turnaround for medical claim filing. Also, they have the real strength and aptitude to make available the flexible times for patient queries from outpatient ambulatory surgery centers to large hospitals.
Nonetheless to share your medical billing success story across healthcare landscape, some essentials should be think through in accordance of what’s being said, demonstrated and delivered at any stage:
Medical Bill Repricing Solutions
It is for this reason, the top medical billing vendor companies are certainly in a successful partnership attitude that lay emphasis on prompt, practical and a patron-centric billing approach. The objective ought to provide excellence attention to injured worker’s compensation claims and effectual charge clarifications. It always starts by real-time bill review besides fake finding for self-insured houses, third-party administrators in addition to insurance companies. Such practices prevent excessive payments and endorse an equitable repricing level for reimbursement.
Non-Network Negotiation
The non-network negotiations possibly will continue to establish the average for fair and reasonable reimbursement aimed at medical billing claims. But getting the substantial discounts on non-network claims and to regulate 100 percent in excess of provider sign-off to ease the risk is always an ideal method used by medical billing vendors. The supplementary healthcare cost suppression approach can be used for any other reporting type in delivering fair and equitable money to the paymaster and reasonable payment to the provider as well.
Fragmentation into coordination
An outsourced medical billing claim service means that you have a complete squad of professionals who make sure that your entitlements get treated swiftly and precisely, sendoff your practice minus at risk to interruptions in cash-flow. When a physician confidence the chosen billing service company and works self-possessed with billing prerogative team, they develop long-lasting benefits like.
More focus on patient care
Improved cash flow
Reduced billing errors
Elimination of training costs
Ensured billing compliance
Decreased call volume
Regular reports about income
Reduction in storage space
Exclusion of costs linked with hiring additional workers
Reduction in patient satisfaction risks
Savings on software, billing equipment and more
Claim denials reduction
Monitoring and Analytics
Your days in A/R, or revenue cycle period has a noteworthy impression on your bottom line. A medical billing service mete out their overheads transversely the all-inclusive client based on providing an economy of scale, monitoring and analytics. Thought, such medical billing vendors can have the funds to chartering with the best staff potential, so that you pay a smaller amount for the comparable and frequently complex collection percentages. In addition to the uninterrupted fiscal advantage of greater returns as well as decreased costs.
Guest post by Lindy Benton, president and CEO, Vyne.
Lindy Benton
The world of denials management is a constantly shifting landscape, one that has changed dramatically with the onset of ICD-10. Now more than ever, denials management requires an organizational focus with built-in workflows for prevention, monitoring and tracking of claims through the system.
In the years leading up to ICD-10, providers were apprehensive about the potential drain it would place on both resources and reimbursement. CMS predicted that – with the onset of ICD-10 – denial rates would increase by 100 to 200 percent, days in A/R would grow by 20 percent to 40 percent and claims error rates would more than double. CMS warned that error rates could reach a high of 6 percent to 10 percent, significantly higher than the 3 percent average error rate with ICD-9.
Providers also feared cash flow problems stemming from coding backlogs, expected to increase by at least 20 percent because of the complexity of the new coding system. “A typical turnaround time for claims processing of 45 to 55 days could end up being extended another 10 to 20 days,” cited Healthcare Payer News.
And the change has been momentous. With ICD-10, the number of diagnostic codes increased from 13,000 ICD-9 codes to 68,000 ICD-10 codes. The new system challenges providers to document conditions more specifically, supporting codes with thorough and accurate medical documentation.
Despite the gravity of the change, many providers say it has been a smooth transition thus far, with minimal delays in productivity and reimbursement. But as the industry moves through this period of adjustment, providers must continue to seek opportunities to protect revenue and generate cash flow for a successful claims management strategy in the wake of ICD-10.
Organizational Approach
ICD-10 requires an organizational focus around the management, prevention and defense of denials. Denials management is no longer an effort reserved just for the revenue cycle but for all departments. For coding to complete a claim, pieces of information must be collected from multiple areas across the organization. For this reason, all departments should be educated on the part they play and how cross-department collaboration can aid the process.
In preparing providers for ICD-10, the Healthcare Financial Management Association (HFMA) noted, “Claims denials will not strictly be a matter of clarification that can be handled by a nonclinical person in the billing office. Denials will raise questions about medical necessity or the clarity of medical documentation supporting a code; such questions will require input from a physician, nurse specialists or outside expertise.”
Workflow processes are also critical as hospitals work to achieve accurate coding and get bills out the door. Technologies that streamline hand-offs between departments can help reduce bottlenecks that often delay reimbursement. A work queue keeps denials moving, assigning and tracking accountability at each checkpoint and monitoring progress to ensure no claim falls through the cracks.
Guest post by Lea Chatham, editor-in-chief, Getting Paid, a Kareo Resource.
Lea Chatham
Patient engagement has been the hot topic of this past year or two. Everyone agrees that engaging patients more in their healthcare can help reduce costs and improve overall health. A study conducted by HIMSS in 2015 showed that the majority of physicians believe patient engagement is beneficial and should be a part of their job. However, the study also concluded that over 40 percent of physicians worry that there is little reimbursement for engagement activities.
Patient are looking for more ways to connect with providers from online scheduling to text reminder to email follow ups and social media. And while many see these as conveniences, the reality is that they do also improve health and have the potential to reduce costs. Studies have shown that simple follow up communications via text and email can help ensure patients show up for appointments and can reduce hospital re-admissions, which has a big impact on healthcare costs.
Unfortunately, physicians are already stretched thin trying to care for patients, run their practices, adhere to complex programs like meaningful use and PQRS, and navigate changes like ICD-10. Who has the time to do more? And many providers worry that “engagement” means more work with less reimbursement. But it doesn’t have to be that way.
In fact there are many opportunities to automate engagement and provide the tools patients want without adding any time or effort to a provider’s plate. Today, there are solutions that once set up enable easy online scheduling, text and email reminders, follow up patient surveys, and even re-care programs.
This infographic highlights some of the feelings of both patients and providers feel about patient engagement and shows how practices can utilize engagement strategies that benefits both and do have a financial return.
These are some of the most out of the ordinary medical codes you might come across if you worked as a medical coder. If you’re a patient and see these on your bill, you might raise an eyebrow once you find out the meanings. Check out the following graphic for all 15 unusual codes.
V94.810 – Civilian Watercraft and Military Watercraft Involved in Water Transport Accident
W56.11 – Bitten by Sea Lion
Y93.D1 – Accident While Knitting or Crocheting
Y92.253 – Hurt at the Opera
If you are interested in being a medical coder, the average salary is $47,870. The job outlook has a 21 percent increase by 2020. Eighty percent of medical coders have some postsecondary education. Medical coders work in both clinical and non-clinical settings, some of which are hospitals, physician offices, long-term care facilities, dental offices, mental health facilities, government agencies, and insurance companies. Graphi provided by Topmedicalcodingschools.com.
Guest post by Amy Sullivan, vice president of revenue cycle sales, PatientKeeper.
Amy Sullivan
The multi-year run-up to the ICD-10 cut-over last October had a “Chicken Little” quality to it. There was prolonged hand-wringing and hoopla about the prospect of providers losing revenue and payers not processing and paying claims – the healthcare industry equivalent of “the sky is falling.”
Then CMS helped calm things down by announcing last July (as the AMA reported at the time), “For the first year ICD-10 is in place, Medicare claims will not be denied solely based on the specificity of the diagnosis codes as long as they are from the appropriate family of ICD-10 codes.”
Since ICD-10 is all about specificity – the number of diagnosis codes increased approximately four-fold over ICD-9 – this was a big relief to all involved. And, if you believe new research data, the sky indeed has not fallen: Sixty percent of survey respondents “did not see any impact on their monthly revenue following Oct. 1, 2015… Denial rates have remained the same for 45 percent of respondents. An additional 44 percent have seen an increase of less than 10 percent.”
Still one has to wonder what will happen after Oct. 1, 2016, when the current leniency expires and ICD-10 code specificity is required. Will physicians be in a position to enter their charges completely and accurately once “in the general neighborhood” coding no longer suffices?
They will if their organization has invested in technology that adheres to best practices in electronic charge capture system design. The three watch-words are: specialize, simplify and streamline.
A charge capture system is specialized when it exposes only relevant codes to physicians in a particular specialty or department, and when it provides fine-tuned code edits. With different types and processes of workflows (and let’s face it, personal preferences), physicians need an intuitive and personalized application that easily fits into their individual work styles. A tailored user experience allows providers to build and display their patient lists in whatever way is most convenient and meaningful to them – down to lists organized by diagnosis and “favorites.”
The 
