The complex and intricate world of medical coding is no simple task. We can all think back to the harrowing year we went from ICD-9 to ICD-10 – or the mid-year COVID updates during the pandemic – as a reminder of how complicated these code updates can get. As we approach another round of CMS’ annual ICD-10-CM code updates, it’s crucial for health plans to stay informed and prepared.

The ICD-10-CM code set for fiscal year (FY) 2025 includes 252 new codes, 36 deleted codes and 13 revised codes. The update also includes a 2025 Conversion Table that identifies inactive ICD-10-CM codes and their replacement codes. These changes are effective from October 1, 2024 through September 30, 2025.

These changes are not merely administrative; they reflect the evolving landscape of medicine, technology and health policy. The complexity of these codes can be daunting and requires extensive knowledge and diligent research. With each update, payers must adapt to numerous changes that impact service billing and insurance claims. Thankfully, a few strategic steps can help resolve some of these challenges. Here are a few tips to help you prepare for the 2025 ICD-10-CM code updates.

Maintenance of claims edits

Updating system processes on day one is important to ensure compliance and avoid having to reprocess claims that have already been paid. Unfortunately, that’s easier said than done, and quick implementation is not always feasible. This is where your payment integrity vendor should be able to do some heavy lifting, including making sure all processes are compliant.

I talked to Craig Van Natta, Vice President of Claims Edits at Zelis, about this, and he offered some helpful insight: “In my experience coming from a health plan, you may not necessarily have those updates in place on day one. Then you’re going to have to go back and reprocess claims that have already been paid. Working with a partner, such as Zelis, helps you make sure you’re not going to pay something incorrectly from an editing perspective.”

Maintaining the quality of edits in the face of these updates requires a robust system and a keen understanding of both old and new codes. Working with a partner who can ensure the edits are high quality is essential for accurate and compliant claims. This not only helps in avoiding costly billing errors but also reduces the likelihood of audits and penalties.

To keep edits high quality, continuous training and development of coding staff are imperative. In addition, using advanced software that can be updated quickly to reflect new codes and guidelines is a critical strategy, helping to identify discrepancies early and serving to reduce the time spent on manual reviews.

Worth noting, it is also important to take advantage of second and even third pass claim editors. Sometimes it’s hard to catch everything on the first pass. Payers can ensure accuracy by expanding their portfolio to include additional editors.

Customizing edits and policies is key

Customizing policies is an important step throughout this process as well. Each payer has different policies and procedures that dictate how codes should be used and billed. This isn’t entirely a one-size-fits-all approach.

“There’s a lot of work to do to just update the codes, and then there’s all those things that come along with it,” Craig adds. “Payers have to ask questions like ‘Are you updating those policies? How are you communicating to your providers about things that may be changing?’”

Payers will benefit from the opportunity to customize edits and policies to incorporate new codes seamlessly. That’s vital for maintaining operational continuity and ensuring claims are processed efficiently.

Ensure clear provider communication

Payers should also make sure to prioritize provider communication as edits are rolled out. More specifically, think through how to effectively communicate these code changes. We’re all aware of the challenges around provider abrasion, and clear, transparent communication is crucial to resolve that tension.

Review your communications plan to share with providers how this will affect billing and service delivery. They need to understand what has changed and how it impacts their day-to-day operations. Ideally, that communication plan takes complex coding information and translates it into actionable insights. This not only ensures the provider knows how to bill correctly but also aids in maintaining a transparent and trustful relationship.

“Most of the time, updates are not that significant,” Craig adds. “But when it is and it does require either a change that’s significant to how an edit operates or it creates an opportunity for additional edits, Zelis actually puts together what we call our one-pager, which is really an explanation of what the edit is or how it should fire.”

It’s important to be proactive about provider communication. They already feel frustrated by the complications in payer policies. Partner with them to ensure they’re informed and eliminate any potential concerns.

The ability to adapt quickly and maintain high-quality edits will have a significant impact on the success of payers to address the upcoming ICD-10-CM code updates. By maintaining robust edit processes, customizing edits and policies, and communicating effectively with providers, payers can navigate these changes efficiently and continue to provide high-quality care.

A claims editing partner can really make a big impact here, and this is a good time to lean into those relationships. They can help with each of these areas so payers can prioritize more important tasks. Our team is constantly working to stay updated on the latest edits. Learn more about all they can do here.