- There is no major overhaul of core office outpatient visits, but CPT 2026 guidance from the American Medical Association (AMA) and policy updates from the Centers for Medicare & Medicaid Services (CMS) affect how some E/M services are billed.
- FY 2026 ICD-10-CM adds hundreds of new codes that change how complexity, risk of complications, and morbidity are documented across everyday healthcare encounters.
- Practices can protect reimbursement and patient care by investing in coders and clinicians through education, stronger documentation habits, and regular claim audits.
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Medical code changes happen every year, and it can be hard for a private practice to track which rules now apply. In 2026, the focus is less on brand-new visit codes and more on updated guidance and diagnosis details that affect how you report E/M codes and other E/M services.
This article looks at key changes to ICD-10-CM effective October 1, 2025, along with 2026 updates that influence visit billing and documentation. The goal is to help your healthcare and billing team send out clean claims, cut avoidable denials, and support accurate patient care and patient management without adding extra confusion for each provider.
Understanding 2026 E/M updates and diagnosis changes
Medical code changes impact almost every part of modern healthcare, from visit billing to follow-up planning. In 2026, core visit E/M codes still rely on medical decision making or total time, but updated guidance and diagnosis changes affect how those services are reported and paid.
Practices depend on accurate CPT codes and HCPCS reporting, guided by current CPT and HCPCS code lists and steady revenue cycle management. The aim is simple: give each provider clear next steps so documentation, patient care, and reimbursement stay aligned.
CMS 2025 E/M booklet and 2026 payment policy changes
In medical billing, E/M codes serve as the backbone of reimbursement processes, linking the The Centers for Medicare & Medicaid Services (CMS) released an updated CMS E/M booklet in September 2025. That guide shapes how Medicare interprets documentation and code selection for E/M services, which means it quietly sets expectations for many private practices.
One important clarification involves HCPCS G2211, the visit complexity add-on. The booklet explains that G2211 can be reported even when modifier 25 appears on the same claim for certain preventive office visits, such as annual wellness visits or vaccines, as long as documentation supports the added complexity.
It also stresses that intravitreal eye injections on the same day as an E/M visit are treated as minor procedures, and the E/M can be billed only when it is significant and separately identifiable, with modifier 25 used correctly.
The booklet also revisits critical care billing rules, reporting for HCPCS G0463, and how telehealth is handled now that many COVID-era flexibilities have expired. These policies are reflected in the Medicare Physician Fee Schedule and the annual final rule, which influence payment for Medicare, Medicaid, and commercial health insurance plans.
When coders and clinicians stay aligned with these coding guidelines, practices are better positioned to avoid denials, keep reimbursement predictable, and support day-to-day healthcare in both clinic and emergency room settings.
FY 2026 ICD-10-CM changes that influence E/M
The FY 2026 ICD-10-CM update adds 487 new, 38 revised, and 28 deleted diagnosis codes. Those changes ripple into medical decision making (MDM) by reshaping how complexity, risk of complications, and morbidity show up in the chart.
When diagnoses are more precise, medical records tell a clearer story about testing, treatment, and follow-up, which supports the level of service you choose for outpatient and hospital inpatient encounters.
- Injuries and poisonings: New codes add more detail for contusions, lacerations, puncture wounds, and open bites, often specifying exact location and laterality. Additional codes describe poisoning and adverse effects from fluoroquinolone antibiotics, the toxic effect of xylazine, and anaphylactic reactions or other adverse reactions to foods. This granularity helps explain diagnostic tests, imaging in radiology, and observation decisions in the emergency department or emergency room.
- Gulf War illness (T75.830): This code reflects a multi-symptom condition seen in Gulf War veterans, with chronic fatigue, headaches, joint pain, and other concerns described by the US Department of Veterans Affairs. It signals long-term patient management needs and often higher MDM.
- Non-pressure chronic ulcers (L98 category): New options capture location, depth, staging, and laterality for non-pressure chronic ulcers. The added detail supports a higher risk of complications, helps justify wound care and imaging, and may support a higher E/M level of service when clinically appropriate.
- Type 2 diabetes in remission (E11.A): Coding diabetes in remission distinguishes these patients from those with active complications. That difference matters for risk scoring, follow-up intervals, and treatment intensity in routine healthcare visits.
- Malignant inflammatory breast neoplasm (C50.A0–C50.A2): These codes describe inflammatory breast cancers with more specific site information, which often aligns with urgent imaging, oncology referral, and more intensive management.
- Cannabis hyperemesis syndrome (R11.16): A dedicated code for this condition helps distinguish it from other causes of vomiting and nausea and can clarify repeated workups in both outpatient clinics and the emergency department.
- Financial insecurity (Z59.862): This code for difficulty paying utilities captures a social driver of health that can affect medication storage, adherence, and overall patient management.
- Genetic susceptibility to disease (for example, Z15.05 and Z15.060): These codes record inherited risk for conditions such as malignant neoplasm of the fallopian tube or colon cancer. Documenting genetic susceptibility supports earlier screening, closer surveillance, and higher perceived risk in MDM.
You can review the official instructions in the FY 2026 ICD-10-CM Official Guidelines. All ICD-10-CM chapters include some level of change for this year except Chapter 8 (H60–H95) and Chapter 22 (U00–U85).
For the complete list of diagnosis changes effective October 1, 2025, see the FY 2026 IPPS ICD-10-CM code tables, especially Table 6A for new codes, Table 6E for revised codes, and Table 6C for invalid or deleted codes.
Documentation and code selection checklist for 2026
A clear note still drives accurate code selection. This checklist can help your team keep 2026 rules in view while staying practical:
- Medical records: Explain why the visit happened, which problems were addressed, and what decisions were made. A good note makes the clinical story easy to follow.
- MDM or total time: State whether medical decision making (MDM) or total time on the date of the encounter was used and give a brief rationale, following the CMS E/M booklet and other coding guidelines.
- Data and tests: Document relevant diagnostic tests, radiology, and labs ordered or reviewed. Tie each item to the problem it addresses and the risk of complications you weighed.
- Non-face-to-face time: Capture qualifying non-face-to-face time, such as chart review, care coordination, and documentation, when it counts toward time-based E/M services.
- Social drivers and risk: Add social factors, like financial or housing issues, and genetic risk codes when they affect patient management or follow-up plans.
- Signatures and timestamps: Make sure the healthcare professional signs the note and dates it, and that time-focused visits include enough detail to support the level reported.
Consistent use of this checklist can help your practice support clean claims and keep documentation aligned with 2026 expectations.
Setting-specific nuances for 2026 (outpatient, inpatient, ED, nursing facility)
The same E/M services framework applies everywhere, but what you document can look different in each setting. Small shifts in focus help support the right level of service across different levels of care.
- Primary care and outpatient services: In primary care and general outpatient services, keep problem lists current, note chronic disease complexity, and describe changes since the last office visit. This detail matters when you choose established patient codes.
- Hospital inpatient: For hospital inpatient encounters, highlight acuity, major comorbidities, and the complexity of care coordination with consultants, nursing, and family. These elements often drive higher visit levels.
- Emergency department: In the emergency department or emergency room, document severity at arrival, immediate diagnostic tests ordered, and the time-critical decisions that shaped treatment or disposition.
- Nursing facility: In a nursing facility, describe baseline status, interval changes, and how multiple chronic conditions are managed over time. This shows why monitoring and visits remain necessary.
- Specialists: Specialists may more often bill higher E/M levels because they manage complex conditions and intensive patient care. Make sure each healthcare professional links findings and plans to the problems addressed.
Staying aware of these nuances, along with broader medical billing trends, can help teams align documentation with 2026 expectations in every setting.
Workflow tips for coders and clinicians in 2026
Good workflows make 2026 changes easier to manage for both coders and clinicians. A few habits can keep everyone on the same page:
- Education and resources for coders: Give your coding team clear, trusted references. That might include AMA and CMS materials, short internal tip sheets, and focused lunch-and-learn sessions or a brief webinar. For structured training and refreshers on E/M codes and E/M services, you can also point them to E/M education from AAPC.
- Provider updates: Build simple updates into existing meetings so each provider hears the same message about new ICD-10-CM codes and E/M policy tweaks. Show how notes can support current coding guidelines, especially for higher complexity visits, time-based reporting, and social or genetic risk factors that require change management.
- Audits and feedback loops: Run small, regular audits instead of one big review at year’s end. Look at whether diagnosis choices match documentation and whether E/M levels fit the clinical story. Share findings in a quick summary so teams can adjust. This helps maintain a compliant healthcare revenue cycle and keeps everyday healthcare work on track.
Next steps for private practices
The 2026 changes are manageable when your practice has a clear plan. Staying current with CPT updates from the AMA and policy changes from CMS helps keep code selection consistent across everyday E/M services.
Using more specific diagnoses strengthens medical decision-making and makes the clinical story easier to follow. Supporting your team with simple workflows, tip sheets, and quick refreshers protects both revenue and patient care.
If your practice wants extra help, Tebra’s EHR software can guide each provider through documentation and E/M workflows.
FAQs
Common questions about E/M coding
- Current Version – Nov 28, 2025Written by: Jean LeeChanges: This article was updated to include the most relevant and up-to-date information available.
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