“With the new updates, the ICD-11 offers more ease of
use, improved interoperability and accuracy, which will benefit national
health systems and the people they serve.” — Dr. Robert Jakob, Team
Leader, Classifications and Terminologies Unit, WHO. World Health Organization
If your revenue cycle, EHR, or compliance teams are still
treating ICD-11 as something “that might happen,” you’re already behind.
I know, I know — we’ve been here before. ICD-10. CPT
changes. HCPCS patches. New code releases. But what’s happening right now is
different. The transition to ICD-11 isn’t just a version bump. It’s a fundamental
structural shift in how diagnoses are coded, how care is documented, how
payers and regulators will audit, and even how medicine data can be used. And
the CPT & HCPCS changes for 2025/2026 add pressure: new codes,
deletions, overlaps, and payers raising compliance expectations.
So I gathered opinions from several experts. I pulled in
what’s fresh—what’s real this week. And I’m delivering this as a survival
guide.
If you’re a physician, coder, compliance officer, medical
billing leader, or HIM (Health Information Management) pro, read this. Even
skim: there are highlighted keywords and statistics so you can scan
fast.
Real-Life Story: When Codes Cost Lives (or Dollars)
Six months ago, a midsize hospital in the Midwest filed a
series of claims for rare disease cases using ICD-10 codes. Their documentation
had key details, but coders didn’t capture severity modifiers. Claims were
denied. Revenue fell. An audit revealed that ICD-10 didn’t allow certain
nuances; under ICD-11, post-coordination and severity modifiers could have
avoided the denials.
Another example: a dermatology clinic started using new CPT
codes for remote therapeutic monitoring in 2025. They assumed vendors would
drop patches automatically. They didn’t. For two months, some services went
unbilled, costing thousands of dollars. Lesson: new codes plus software plus
human oversight is a must.
Key Statistics
- As
of May 2024, 132 WHO Member States / areas are in various phases of
implementing ICD-11: 72 have begun implementation (including
translations), 50 are in pilot or expansion phases, and 14 have begun
collecting or reporting data using ICD-11. World Health Organization
- The mapping
success rate from ICD-10 to ICD-11 for adult deaths in Alberta
(Canada) was about 96.6% for adult codes, and 100% for
children and infants. Patient-level mapping success was ~99.5% for adults.
BioMed Central
- ICD-11
has ~ 55,000 more clinical concepts than ICD-10 according to some
comparisons, offering much greater specificity and detail; in contrast,
ICD-10 had around ~14,000 codes in certain use settings. Sprypt
- For
the 2025 CPT code set: there are 270 new codes, 112 deletions,
and 38 revisions. I-Med Claims
- Claim
denial rates are rising: according to the Change Healthcare Denials Index,
denials are now 10-15% of submitted claims, up from ~6-10% a decade
ago. Coding errors & documentation issues are major contributors. uasisolutions.com
- Coding
mistakes, including using incorrect ICD-10/11, CPT, or HCPCS codes,
contribute to about 25% of claim denials. Aspect Billing Solutions
- In
studies assessing the validity of ICD-10 administrative data (for
comorbidity coding in Alberta, Canada), there was an under-coding trend
over time: mean differences between chart reviews vs coded data rose from
~2.1 % in 2003, ~7.6 % in 2015, and ~6.3 % in 2022 for 17 clinical
conditions. arXiv
What’s Fresh This Week: Key Updates & Pressures
The ICD-11 2025 release adds multilingual support,
expanded modules for traditional medicine like Ayurveda and Unani, better error
detection, and smarter interoperability with MedDRA and Orphanet. CMS has
finalized the HCPCS Level II determinations for the 2025
non-drug/non-biological cycle. The CPT 2025 code set includes 270 new
codes, 112 deletions, and 38 revisions, including updates to remote therapeutic
monitoring codes. ICD-10-CM changes for FY 2025 include 252 additions, 13
deletions, and 36 revisions. Researchers are emphasizing that ICD-11’s
complexity, vendor readiness, and documentation training remain the biggest
challenges and opportunities.
Expert Round-Up: Voices From the Field
Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, who
leads Revenue Integrity and HIM for a major health system, says the key is to
start early with clinical documentation integrity. ICD-11 demands
specificity and severity detail. If documentation doesn’t capture it, coders
can’t code it. She also stresses involving leadership early so policies,
budgets, and vendor planning are in place.
Laura Legg, RHIA, RHIT, CCS, CDIP, VP of Coding
Division at Coronis Health, warns that ICD-11 is a workflow challenge, not just
a code update. Without clinician training, DRG mapping, and tech upgrades, the
risk is significant: revenue disruption, denials, and regulatory scrutiny.
Compliance and coding leadership at AMA and CMS point out
that CPT changes are more aggressive than usual. Practices that wait until late
December to update systems often experience claim rejections. They emphasize
that payers are tightening edits and audits, particularly around remote
services and device/supply billing.
Tactical Tips: What You Can Do Now
Start with documentation audits. Check if your most common
diagnoses include severity, complications, and modifiers. Then review your
systems and vendors: make sure your EHR and billing software can handle ICD-11
logic and CPT/HCPCS updates.
Train everyone involved — coders, clinicians, front-office
staff — and use short, focused modules. Consider running pilot programs or dual
coding projects to compare ICD-10 and ICD-11 results.
Audit claims before submission, and simulate payer audits to
catch errors before they cost money. Communicate with payers early to learn
about their timelines. Finally, budget for the transition, including software
upgrades, training costs, and compliance resources.
Failures I’ve Heard (So You Don’t Repeat Them)
The most common failure is waiting until codes are mandated,
which creates a backlog and confusion. Another is assuming vendors will handle
everything; many don’t fully support ICD-11 post-coordination yet.
Under-estimating clinical documentation gaps is another big one — coders can’t
invent details that aren’t documented. And finally, practices often forget to
budget for the “soft costs,” such as time for staff training and workflow
redesign.
The Controversial Truth About ICD-11 and Coding “Best
Practices”
Here’s a hot take: Most organizations are over-preparing
for ICD-11 — and under-preparing for its impact on culture, workflow, and
trust.
We obsess over crosswalks, code mapping, and EHR upgrades,
but the real bottleneck is clinician behavior. If documentation
quality doesn’t improve, ICD-11 will simply magnify the same old gaps — missing
laterality, vague diagnoses, under-documented comorbidities — and amplify
denials.
Three “Best Practices” Worth Questioning:
- “Just
crosswalk ICD-10 to ICD-11”
Truth: Automated crosswalks fail in 20–30% of high-impact cases. Post-coordination means coders must make judgment calls. Blindly trusting automation could cost millions in mis-coded claims. - “Training
is a one-time event”
Truth: ICD-11 is dynamic. It evolves faster than ICD-10 ever did. Training should be continuous, modular, and data-driven — not a single lunch-and-learn session. - “Wait
for payers to be ready”
Truth: Early adopters will negotiate payer contracts faster, uncover mapping issues before go-live, and avoid revenue shocks. Late movers will scramble when ICD-10 sunset deadlines hit.
Why This Matters
The industry tends to focus on technical readiness,
but cultural readiness — clinician buy-in, coder confidence, and
leadership alignment — will make or break this transition. ICD-11 is not just a
“billing project.” It’s a clinical language upgrade that requires
clinicians to think differently about documentation.
“Coding is storytelling — if the story is incomplete, no
software can fix it.”
– Dr. Alan Rivera, MD, Clinical Informatics Expert
My Challenge to the Industry
Instead of asking, “When will our system be ready?”,
we should ask:
“When will our clinicians be ready to tell a more accurate story of care?”
If we shift the focus to documentation culture first,
technology will follow — and the transition will feel like an upgrade, not a
compliance headache.
Questioning “Industry Best Practices”
“Wait until mandate” is risky advice. By the time ICD-11 is
required, your backlog may already be hurting cash flow. Another so-called best
practice is simply sending an email memo about coding changes. In reality,
people need role-play and feedback sessions to internalize new requirements.
Myth Buster Section
ICD-11 is not just a more detailed ICD-10. It introduces
post-coordination, severity modifiers, and new chapter structures that require
new workflows. Another myth is that ICD-10 will always be accepted. Payers will
begin demanding ICD-11 as soon as they are ready, and dual coding may be
necessary. Finally, some believe CPT updates only affect specialties like
surgery or radiology, but new codes like remote monitoring and supply codes
ripple into nearly every specialty.
Keyword-Rich Quick Takeaways
Search or check your systems for post-coordination, severity
modifiers, clinical documentation integrity, interoperability,
DRG alignment, remote therapeutic monitoring, and HCPCS Level
II updates. These terms will drive most of your 2025 coding priorities.
FAQs
When will ICD-11 be implemented in the U.S.?
There’s no final date yet, but projections suggest 2025-2027 for phased
rollout.
Will ICD-11 replace ICD-10 right away?
No — dual coding will likely run for some time, with payers setting their own
timelines.
What’s the biggest revenue risk?
Documentation gaps, untrained staff, and software that doesn’t support the new
coding logic.
How many new CPT codes are in 2025?
There are 270 new codes, 112 deletions, and 38 revisions.
Three Expert Strategies You Can Use
First, begin shadow coding now to compare ICD-10 and
ICD-11 outputs. Second, develop modular training programs that include
case studies and real scenarios. Third, set up a governance team that
owns this transition and monitors rejection rates, coding errors, and
compliance milestones.
Tools, Metrics & Resources to Win the ICD-11
Transition
The ICD-11 shift is not just a compliance project —
it’s a long-term upgrade for your data and revenue cycle. Here’s a curated
list of tools, metrics, and resources that busy medical professionals can
rely on right now.
Essential Tools & Platforms
- Clinical
Documentation Improvement (CDI) Software – Look for platforms with real-time
prompts that flag missing severity modifiers and support ICD-11
post-coordination (e.g., 3M 360 Encompass, Optum CDI, Clintegrity).
- AI-Driven
Encoder Tools – Leverage NLP-powered encoders that can auto-suggest
ICD-11 codes and reduce human workload while maintaining audit trails.
- EHR
ICD-11 Test Environments – Secure a sandbox with dual coding
capability to simulate end-to-end billing.
- Denial
Management Dashboards – Revenue cycle tools like Waystar, Experian, or
internal Power BI dashboards that track denial rates, root causes,
and time to resolution.
- Learning
Management Systems (LMS) – For role-based training with automated
competency tracking and analytics (Relias, HealthStream, or even custom
LMS).
Key Metrics to Track (Your North Star KPIs)
Tracking the right metrics keeps your team focused on impact,
not activity.
- Claim
Acceptance Rate: Target ≥ 98% clean claim rate within 30 days
post-go-live.
- Denial
Rate by Category: Watch for spikes in medical necessity or
coding-related denials — your early warning system.
- Revenue
Impact Variance: Monitor net revenue change per DRG or service line to
ensure financial neutrality or positive lift.
- Coding
Accuracy Rate: Internal or external audit accuracy ≥ 95% (dual-coded
sample).
- Clinical
Documentation Completeness: % of charts meeting CDI criteria (e.g.,
laterality, specificity, acuity).
- Coder
Productivity: Charts coded per FTE per day (to measure impact of
ICD-11 complexity).
- Training
Completion & Competency: ≥ 90% pass rate on post-training quizzes.
Recommended Resources
For leaders who want to dig deeper, here are curated credible,
up-to-date references from this week:
- WHO
ICD-11 Implementation Toolkit – A practical guide for policy makers
and HIM teams preparing for ICD-11 adoption.
Read the WHO ICD-11 Toolkit - AMA
CPT® 2025 Code Set Updates – Detailed summary of new CPT codes for
digital health, telemedicine, and AI-driven services.
Explore AMA CPT 2025 Updates - CMS
HCPCS Quarterly Update – Official Q3 2025 release notes covering
device codes, drug codes, and supply chain impacts.
Review CMS HCPCS Updates
Expert Tip:
“You can’t manage what you don’t measure — make metrics
visible to clinicians and leadership. When they see the link between
documentation, coding, and revenue, behavior changes faster.”
– Maria Gonzalez, RHIA, Director of Health Information Management
Tactical Advice:
- Automate
KPI dashboards — don’t wait for monthly reports.
- Share
success stories: show clinicians how one extra detail avoided a denial.
- Update
metrics quarterly to reflect CPT/HCPCS changes, not just ICD-11 adoption.
Step-by-Step Roadmap — Preparing for ICD-11, CPT &
HCPCS Updates
Short intro: below is a practical, actionable,
step-by-step plan your organization can use to prepare for the ICD-11
transition and the ongoing CPT / HCPCS churn. Each step
includes who should own it, what to deliver, timing, and success
criteria. Read fast or use it as your project blueprint.
Quick checklist
- Establish
governance and assign a transition owner.
- Run shadow
coding (ICD-10 vs ICD-11) on priority diagnoses.
- Audit
documentation for severity modifiers and post-coordination
needs.
- Test
EHR and billing systems with end-to-end claim scenarios.
- Train
clinicians + coders with short, role-based modules.
- Engage
payers for acceptance rules and testing.
- Monitor
denials and iterate.
Step 1 — Form Governance & Project Team (Owner: CIO /
CMO / Revenue Lead)
What: Create a cross-functional steering committee
(HIM, CDI, Coding, Revenue Cycle, Clinical Champions, IT/EHR, Compliance,
Legal, Finance). Appoint a Program Manager.
Timing: Immediate (0–2 weeks).
Deliverable: Charter with scope, budget estimate, milestones, and RACI.
Success: Charter approved and stakeholders committed.
Why: Centralized decision-making prevents mismatched
priorities and budget gaps. This is your single source of truth for revenue
cycle and compliance choices.
Step 2 — Discovery & Inventory (Owner: HIM / IT)
What: Inventory systems, contracts, and code
dependencies: EHR modules, encoder software, billing engines, third-party
vendors, custom mappings, templates, and interfaces. Identify high-volume DRGs,
high-margin CPTs, and devices billed with HCPCS Level II.
Timing: 2–4 weeks.
Deliverable: Systems and code-dependency register + impact heatmap.
Success: Identified “hot” areas (top 20 codes/DRGs by revenue and top
denial causes).
Tip: Highlight vendors that claim ICD-11 support
and vendors that don’t.
Step 3 — Documentation Gap Analysis (Owner: CDI /
Clinical Leads)
What: Audit a sample of charts for your top diagnoses
to check for missing severity modifiers, laterality, and details needed
for post-coordination.
Timing: 3–6 weeks (parallel).
Deliverable: Gap report with examples and required template changes.
Success: List of specific documentation items clinicians must capture.
Tip: Use real charts and include clinician champions
to avoid “this won’t work in practice” feedback.
Step 4 — Mapping Strategy & Dual Coding Plan (Owner:
HIM / Coding Leads)
What: Decide your mapping approach (automated
crosswalks + manual validation). Implement a dual coding / shadow coding
pilot where selected encounters are coded in ICD-10 and ICD-11 concurrently.
Timing: 1–3 months to start; ongoing.
Deliverable: Mapping rules, exceptions list, and comparative report
showing code differences and revenue impact.
Success: Pilot shows actionable changes (documentation or workflow) and
identifies ambiguous mappings.
Keyword note: Test for post-coordination needs
and where automated mapping fails.
Step 5 — Vendor & EHR Readiness (Owner: IT / Vendor
Mgmt)
What: Engage EHR and encoder vendors for timelines,
technical capabilities (FHIR/APIs, semantic tagging, support for
post-coordination), and patch schedules for CPT/HCPCS updates. Secure a test
environment.
Timing: Start immediately; get commitments within 4–6 weeks.
Deliverable: Vendor readiness matrix and test plan.
Success: Written vendor timeline for feature delivery and test slots
reserved.
Pitfall: Don’t assume automatic vendor rollouts—get
dates, release notes, and test access.
Step 6 — Build Test Scripts & End-to-End Claim
Testing (Owner: Revenue Cycle / IT)
What: Create realistic test cases that include
clinical documentation, encoding, claims generation, and payer responses
(including edge cases like severity escalation, device/supply billing, RTM).
Run end-to-end claim tests in sandbox environments.
Timing: 2–4 months to develop and run initial cycles.
Deliverable: Test scripts, defect log, remediation plan.
Success: Zero critical defects in top 50 revenue scenarios.
Tip: Include CPT and HCPCS updated
codes in test claims and monitor edits.
Step 7 — Training & Change Management (Owner: HR /
Education / Clinical Leaders)
What: Design role-based training: short modules for
clinicians (documentation changes), coders (ICD-11 structure,
post-coordination), front desk (intake prompts), and billing teams (new
CPT/HCPCS rules). Use case studies, short videos, quizzes, and competency
signoffs.
Timing: Begin 2–3 months before pilot go-live; continue with ongoing
sessions.
Deliverable: Training curriculum, attendance logs, competency tests.
Success: ≥90% competency pass rate in pilot departments.
Keyword: Emphasize clinical documentation
integrity in every clinician module.
Step 8 — Pilot / Phased Rollout (Owner: Project Manager /
Clinical Champions)
What: Run a controlled pilot (one service line or
site). Use dual coding to compare outputs, evaluate denial rates, and
capture clinician feedback. Scale in phases by complexity and revenue impact.
Timing: Pilot 1–3 months; phased scaling over next 6–12 months.
Deliverable: Pilot report with KPIs and go/no-go recommendations.
Success: Acceptable denial rate and clinician satisfaction; clear path
to broader rollout.
Step 9 — Payer Engagement & Contract Review (Owner:
Revenue Cycle / Legal)
What: Communicate with major payers about their
ICD-11 acceptance plans, claim submission expectations, and preauthorization
rules. Update contracts if needed and seek payer test windows for claims.
Timing: Start early and continue through rollout.
Deliverable: Payer readiness log and test confirmations.
Success: At least 80% of volume payers confirm support or provide
timelines.
Tip: Ask payers for prioritized testing on high-value
codes.
Step 10 — Audit, Compliance & Denial Management
(Owner: Compliance / HIM / Revenue Analytics)
What: Implement pre-submission and post-submission
audits. Use mock audits to test medical necessity documentation against
new coding expectations. Create fast denial triage and remediation workflows.
Timing: Begin pre-go-live and continue forever.
Deliverable: Audit templates, denial playbooks, rework SLAs.
Success: Reduction in denial rate for pilot by X% (define target
baseline).
Metric ideas: Claim acceptance rate, denial rate by
reason code, time to rework.
Step 11 — Full Rollout & Go-Live (Owner: Program
Manager)
What: Execute phased expansion using lessons from
pilot. Communicate daily standups during initial go-live weeks. Keep hot teams
for incident response (IT, coding SMEs, vendors).
Timing: Rollout phases over 3–12 months depending on size.
Deliverable: Go-live checklist and incident log.
Success: Stable claims processing and controllable rework volumes.
Contingency: Have rollback or parallel processing
options for critical interfaces.
Step 12 — Continuous Monitoring & Optimization
(Owner: HIM / Revenue Ops)
What: Monitor KPIs continuously: denials, claim
turnaround, coding error rate, documentation improvements, clinician feedback,
and payer edits. Run quarterly retrospectives and update training.
Timing: Ongoing.
Deliverable: Dashboard and recurring improvement backlog.
Success: Progressive improvement trend and fewer high-impact exceptions
each quarter.
Keyword: Use analytics to measure DRG alignment
and revenue integrity.
Risks & Mitigations (Short bullet list)
- Risk:
Vendor delays → Mitigation: contract clauses, parallel manual
processes.
- Risk:
Clinician resistance → Mitigation: clinical champions + quick wins
+ time-saving templates.
- Risk:
Unexpected denial spikes → Mitigation: immediate denial triage team
+ payer escalation.
- Risk:
Mapping ambiguity → Mitigation: clinical adjudication board +
documentation updates.
Sample 12-Month Timeline
- Months
0–1: Governance, discovery, inventory.
- Months
1–3: Documentation audit; vendor scoping; mapping plan.
- Months
3–6: Pilot dual coding; build tests; initial training.
- Months
6–9: Pilot evaluation; payer testing; scale training.
- Months
9–12: Phased go-live; intensive support; begin continuous monitoring.
Success Metrics (KPIs to track)
- Claim
acceptance rate (pre/post).
- Denial
rate (by reason).
- Time
to code / code turnaround.
- % of
charts meeting CDI documentation standards.
- Revenue
variance attributable to coding changes.
- Vendor
defect rates in testing.
Quick Templates You Can Use
- Pilot
Sign-Off Criteria: 95% acceptance on core claims; <X% denied for
documentation reasons; documented clinician feedback closed.
- Training
Module Title: “ICD-11 Essentials for Clinicians — What to Document
Today.” (15 minutes)
- Payer
Message Subject Line: “Request: ICD-11 / CPT/HCPCS Sandbox Testing
& Timeline — [Organization Name]”
Final tips
- Start
small and test often.
- Measure
everything. Data beats opinions.
- Keep
clinicians in the loop — they are your single biggest lever.
- Treat ICD-11
as a long-term modernization opportunity, not a one-time compliance event.
Key Differences in Plain Words
ICD-11 uses a stem code plus post-coordination model,
allowing for more detail than ICD-10’s single-code approach. It has more
chapters, new sections for traditional medicine, and better digital design.
Documentation must be more detailed to capture severity and context. CPT and
HCPCS updates continue annually or biannually, and staying on top of them is
crucial to avoid denials.
Future Outlook: The Next 3–5 Years in Medical Coding
The next few years will not just be about flipping a switch
to ICD-11 — they will reshape how we think about clinical data, compliance, and
reimbursement. Here’s what’s coming:
- ICD-11
Goes Mainstream: Expect pilot programs to give way to nationwide
adoption in the U.S. by the latter half of this decade. Hospitals and
payers will push for dual coding first, then full transition.
- AI-Assisted
Coding Becomes the Norm: Natural language processing (NLP) and
AI-driven encoders will handle much of the first-pass coding, with human
coders focusing on edge cases, compliance review, and quality checks.
- More
Frequent CPT & HCPCS Updates: As digital health, AI, and remote
care expand, new CPT codes will roll out annually — sometimes mid-year —
to capture innovations. Practices must get faster at implementation to
avoid lost revenue.
- Global
Interoperability & Analytics: ICD-11’s digital-first design will
allow better international comparisons, population health analytics, and
value-based care tracking. This will make data quality a strategic
differentiator.
- Regulatory
& Payer Pressure: Expect more audits focused on documentation
integrity and medical necessity, with penalties for poor coding or
under-reporting of severity.
The winners in this space will be those who see
coding not as a compliance burden but as a strategic advantage — a way to tell
a more accurate story of patient care, improve outcomes, and secure fair
reimbursement.
Final Thoughts
The transition to ICD-11 and the 2025 updates to CPT and
HCPCS are more than administrative tasks — they will affect patient care,
revenue, and compliance. Preparing early will make this an opportunity,
not a crisis.
Get Involved
Get involved, join the movement, step into the conversation,
start your journey, be part of something bigger, engage with the community, get
on board, jump in, raise your hand, be the change, lend your voice, take the
first step, start learning, build your knowledge base, explore the insights,
have your say, contribute your ideas, share your voice, help shape the future,
be a thought leader, support the mission, fuel your growth, unlock your next
level.
References
- WHO
ICD-11 Implementation Overview – details on adoption, tools, and
transition strategies. Read on WHO’s site
- McGovern
Medical School 2025 Coding Compliance Changes – list of ICD-10-CM
additions, CPT updates, and compliance changes. See full resource
- ICD-11
in 2025: Evolution and Global Progress – expert commentary on adoption and
readiness planning. Read on ICD10Monitor
About the Author
Dr. Daniel Cham is a physician and medical consultant with
expertise in medical tech consulting, healthcare management, and medical
billing. He focuses on delivering practical insights that help professionals
navigate complex challenges at the intersection of healthcare and medical
practice. Connect with Dr. Cham on LinkedIn to learn more:
linkedin.com/in/daniel-cham-md-669036285
Disclaimer
This article provides an overview of the topic and is not
legal or medical advice. Consult appropriate professionals for specific
guidance.
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