Three new rules/regulations to watch, effective Oct. 1

By Brian Murphy

Thursday, Oct. 1 is the start of three big changes hitting the mid-revenue cycle all at once. 1) Updated ICD-10-CM Official Coding Guidelines, 2) New/deleted/revised ICD-10 codes, 3) new IPPS regulations.

Here’s a summary with added focus on the OCG because I’ve covered 2 and 3 prior.

Official Coding Guidelines

The OCG updates are minimal. Helpfully, these are in BOLD font and easy to find. Here’s a short summary:

• Chapter 9, Hypertension with heart disease: The guidelines currently allow coders to assume a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, even in the absence of provider documentation. This has been expanded to include the notation of “one or more heart conditions” in place of a singular.
• Chapter 17, Congenital malformations, deformations, and chromosomal abnormalities has been expanded to include “genetic disorders” with that instruction added throughout.
• Chapter 21, a brand-new guideline added for Z84.A—Family history of exposure to diethylstilbestrol (DES). DES is an artificial, man-made form of the female hormone estrogen widely prescribed to pregnant women from 1938-1971 to prevent miscarriages and pregnancy complications. It was later linked to increased risk of high cholesterol, hypertension, and heart issues. Note this code pertains to family history of exposure, with the example given of a patient’s maternal grandmother exposed to DES and thereby making the patient susceptible.

Again, quite minor.

New/revised codes

More significant are the new codes. These include 190 new codes, 30 deleted codes, and 4 code revisions.

I’ve written about these before (see link below). The most relevant/eye-catching change is two new codes adding BMI specificity in the lower range, replacing the familiar Z68, as follows:

• Delete: Z68, Body mass index [BMI] 19.9 or less, adult
• Add: Z6818, Body mass index [BMI] 18.4 or less, adult
• Add: Z6819, Body mass index [BMI] 18.5-19.9, adult

Cardiology saw some major updates. CMS expanded coding options for cardiomyopathies and cardiac arrhythmias, adding distinctions for familial-genetic dilated cardiomyopathy (I4201), arrhythmogenic cardiomyopathy (I4281), Brugada syndrome (I4981), catecholaminergic polymorphic ventricular tachycardia (CPVT, I4722), ventricular bigeminy, and other rhythm disorders.

IPPS final rule

The 2027 IPPS final rule includes several important changes, from the new expanded joint replacement bundled care model (CJR-X) to the addition of sepsis to the hospital readmissions reduction program (HRRP) beginning in fiscal year 2029.

The HRRP is penalty-only. Hospitals are penalized up to 3% of Medicare payments for higher-than-expected readmission rates for certain conditions, including acute myocardial infarction (AMI), heart failure (HF), pneumonia, COPD and others. Add sepsis to the list. While payment reductions don’t start until Oct. 1, 2028, sepsis data collection has already begun (July 1, 2025 – June 30, 2027).

CJR-X is the first mandatory, nationwide test of an episode-based payment model and begins on January 1, 2028. Which means education and improved care coordination efforts should begin now.

There are several new CCs/MCCs and a few deletions. I’ve listed them at the link below.

References

• CMS, Official Coding Guidelines: https://www.cms.gov/files/document/fy-2027-icd-10-cm-coding-guidelines.pdf
• Norwood, New ICD-10 codes: https://www.norwood.com/new-2027-icd-10-codes-are-out-effective-oct-1-what-you-need-to-know/
• Norwood, CC/MCC changes: https://www.norwood.com/cc-mcc-changes-in-2027-ipps-final-rule-we-summarize-them-for-you/