How to Write DAP Notes for Different Therapy Modalities (CBT, DBT, and Trauma-Informed Care)

omni — Wed, 08 Apr 2026 13:27:45 +0000

How to Write DAP Notes for Different Therapy Modalities (CBT, DBT, and Trauma-Informed Care)

After reviewing thousands of progress notes written by clients, I have come to believe that the quality of your notes reflects the quality of your clinical thinking. Not always. But more often than you would expect.

A clinician who writes vague, generic therapy notes usually is not doing sharp, focused clinical work in the room. A clinician who writes crisp, modality-grounded counseling notes almost always brings that same precision to their sessions.

This blog covers how to write DAP notes across three of the most common frameworks in practice today:

Cognitive Behavioral Therapy
Dialectical Behavior Therapy, and
Trauma-Informed Care

It includes real examples, specific tips, and the hard-won principles that separate documentation that protects your clients from documentation that just fills a chart.

What the DAP Notes Template Is Asking You to Do

DAP stands for Data, Assessment, and Plan. It is one of the most widely used formats for clinical documentation and progress notes. On the surface it looks simple. Write what happened, interpret it, say what comes next.

But the format contains a trap that catches almost every clinician at some point.

The trap is that most people treat the Data section as the whole note. They write two sentences about what the client talked about, copy a plan from the last session, and call it done.

The Assessment section, which is where the actual clinical thinking belongs, gets one sentence. Something like “client is making progress toward treatment goals.” That sentence is not an assessment. It is a placeholder.

Here is what each section of a strong DAP notes template is actually asking for.

Data: What you observed and what the client reported. Mood. Presentation. What they brought into the room. What you noticed that they did not say out loud. A good Data section reads like a specific account of this session, not a template filled in with interchangeable content.

Assessment: Your clinical interpretation of the data. This is where you think on paper. What does this client’s presentation tell you right now, in the context of their history, their diagnosis, and their treatment goals? A real assessment is three to five sentences of actual thinking, not a restatement of the Data.

Plan: A record of your clinical decision-making, not just a to-do list. Why are you moving forward with this intervention? Why are you slowing down? What did the client agree to? What are you watching for?

When all three sections work together, the data generates the assessment, and the assessment drives the plan.

Writing DAP Notes for Cognitive Behavioral Therapy (CBT)

CBT gives you one of the cleanest fits with the DAP format. The model is structured, the interventions are named, and the goals are measurable. In theory, CBT progress notes should be the easiest to write well.

In practice, two problems show up consistently.

The first is that clinicians document the content of the session instead of the process. They write what the client said about their anxiety rather than what the client did with the thought record or how they responded to the cognitive restructuring. Content is background. Process is evidence of treatment.
The second is that the plan reads like a to-do list with no clinical reasoning. “Will continue CBT techniques next session” tells a supervisor, an insurer, or a colleague covering your caseload absolutely nothing about where this client is in treatment or what needs to happen next.

The Data section in CBT notes

Start with the mood rating if you use one. Not just the number, but what it means relative to baseline. A 5/10 from a client who was at 2/10 four sessions ago is a different clinical picture than a 5/10 from someone stuck there for eight weeks.

Document homework. Not just whether they did it, but what it revealed. A client who completed their thought record but filled every entry with the same automatic thought, word for word, is telling you something important about rigidity. A client who did not complete it but can articulate exactly why is showing you avoidance. That distinction belongs in the note.

Name the specific cognitive distortions you identified. Catastrophizing. Mind reading. All-or-nothing thinking. “Negative thinking patterns” is not specific enough. Precise language in the Data section forces precision in the Assessment.

DAP note example: CBT data section

Client presented at 4/10, down from 6/10 last session, citing three panic episodes at work this week. Homework review revealed completed thought records but client applied catastrophic interpretations to every entry. Automatic thought identified in session: “If I feel anxious, something bad is about to happen.” Client showed limited insight into the interpretation as a pattern rather than a fact. Behavioral avoidance of the break room reported for the second consecutive week.

The Assessment section in CBT notes

This is where most CBT notes fall apart. The Data section is specific and the Assessment is one vague sentence. The gap between the two is where your clinical thinking is supposed to live.

Your assessment should answer: what does this data mean for this client’s treatment right now?

You named catastrophizing in the Data section. Your Assessment should tell whether that pattern is intensifying, softening, or staying fixed. It should connect to the diagnosis. It should comment on the pace of treatment.

One rule I prefer is that if you could copy your Assessment from this session into last session’s note and it would still read as accurate, you have not written an assessment. You have written a placeholder.

DAP note example: CBT assessment section

Client’s return to lower mood ratings following two weeks of improvement suggests the current performance review at work is functioning as a maintaining factor for anxiety. Thought records show intellectual engagement but limited internalization of cognitive restructuring. The rigidity in her automatic thought content warrants introduction of a longitudinal evidence review next session. Behavioral avoidance is expanding, not contracting, which suggests homework intensity may be exceeding her window of tolerance for exposure. Pacing adjustment is indicated.

The Plan section in CBT notes

A strong CBT plan names the specific skill or technique, the clinical reason for choosing it, and what the client agreed to do between sessions. If you are adjusting your approach, say so and say why.

DAP note example: CBT plan section

Will introduce a historical evidence log next session to address rigidity in catastrophic thinking. Will reduce homework to one thought record per day given signs of avoidance related to volume. Will reintroduce break room exposure as a graded step rather than a full return. Client agreed to practice diaphragmatic breathing before entering the break room regardless of anxiety level. Will reassess mood trajectory before continuing with thought challenging.

Writing DAP Notes for Dialectical Behavior Therapy (DBT)

Most DBT clients are in active distress much of the time, and your notes are part of a safety net. If something goes wrong, your notes will be read by supervisors, insurers, lawyers, and licensing boards. They need to show that you were paying attention, following the treatment model, and responding appropriately to risk.

The most common mistake in DBT therapy notes is what I call the summary trap. The clinician writes a paragraph describing the session like a story and buries the clinical information inside it. The diary card review is mentioned in passing. The self-harm urge rating is missing. The chain analysis is described as “we discussed the behavior” rather than documented as a clinical intervention.

DBT has a structure. Your notes need to reflect that structure, because that is what demonstrates you are actually doing DBT and not just having supportive conversations with a high-risk client.

The Data section in DBT notes

Always lead with the diary card. Every single session. If the client did not bring one, document that and what you did instead. Therapy-interfering behavior is clinically significant data in DBT and belongs in the note the same way a self-harm urge does.

Document the target hierarchy explicitly. Life-threatening behaviors first, then therapy-interfering behaviors, then quality-of-life issues. If urges to self-harm were present, give me the numbers. Not “client reported some urges.” Give me the peak rating, the frequency, whether any urges moved toward behavior, and what stopped them. That specificity is what allows you to track trajectory and demonstrate movement in treatment.

DAP note example: DBT data section

Diary card reviewed. Client reported urges to self-harm on four of seven days, peak intensity 7/10 on Wednesday following conflict with her mother. No acts of self-harm. One incident of alcohol use Thursday evening. Therapy-interfering behavior noted: client arrived 15 minutes late. Affect on arrival was constricted. Dysregulation visible in session when discussing Wednesday; affect stabilized within 20 minutes using TIPP. Skills group attended. Client reported using Opposite Action once during the week.

The Assessment section in DBT notes

Your assessment should map directly onto the target hierarchy. Where is this client right now? Is Stage 1 work still the priority or is something shifting?

Do not skip the skills assessment. DBT is a skills acquisition model. Part of your clinical job is tracking which skills the client knows, which ones they can access under stress, and which are still theoretical. A client who can recite TIPP but never uses it in a moment of distress is at a different stage than a client who reaches for it imperfectly but genuinely. That distinction belongs in your assessment.

DAP note example: DBT assessment section

Client remains in Stage 1 of DBT treatment. Urge frequency and intensity are elevated this week relative to the prior three weeks, consistent with the increase in interpersonal conflict with her primary attachment figure. No movement to behavior represents meaningful progress given prior history. Late arrival and initial affect constriction are patterns consistent with approach-avoidance around emotionally significant material. Client is beginning to access distress tolerance skills in session with prompting; generalization to real-world crises has not yet occurred.

The Plan section in DBT notes

In DBT, the plan section should always address risk first, then the clinical work. Document the safety planning conversation, not just the outcome.

“Safety plan reviewed and intact” is not enough. Who did the client identify as a contact? Did she commit to using the crisis line before acting on urges? What was her affect when she made that commitment? Flat compliance and genuine buy-in are different things, and the difference matters clinically.

DAP note example: DBT plan section

Safety plan reviewed in full. Client identified her sister and crisis line as first-step contacts. She was able to state this with moderate affect, an improvement from previous sessions where she was dismissive of the plan. Will conduct full chain analysis of Wednesday conflict next session. Client agreed to complete diary card daily. Will introduce GIVE skills targeting the interpersonal pattern that is currently driving urge spikes. Will consult with DBT team before next session regarding pacing.

Writing DAP Notes for Trauma-Informed Care

Trauma work is where the most documentation errors, and they are almost always the same error: the clinician documents what was said about the trauma instead of what happened in the room during the session.

A client discloses something significant. The clinician, wanting to honor the disclosure, writes a detailed account of it. Three paragraphs. Specific details. Dates, names, descriptions of what happened.

That is not a clinical note. That is a transcript. And it can cause real harm if the record is subpoenaed, accessed by another provider without context, or reviewed years later by the client themselves.

In trauma-informed practice, the clinical story is not what happened to the client in the past. The clinical story is what happens in the client’s nervous system in the present, and what you do in response. That is what the note should capture.

The Data section in trauma-informed notes

Document the client’s nervous system state, not just their mood. There is a meaningful difference between a client who presents as flat and a client who is hypoactivated. Between a client who seems agitated and a client who has left their window of tolerance. Use the clinical language that matches your framework. It shows you are tracking what is actually happening and not just noting surface affect.

Document the specific interventions you used and in what sequence. If you shifted from a somatic exercise to grounding because the client was escalating, say so. If you decided not to proceed with trauma processing because the client was already activated, say that and say when you made that decision. Clinical decision-making in real time is exactly what trauma-informed notes need to capture.

DAP note example: trauma-informed data section

Client presented within window of tolerance initially. Became visibly hyperactivated approximately 20 minutes into session (rapid breathing, startle response, dissociative markers including eye glazing and delayed responses) when discussing the previously referenced incident. Reported feeling “like I am back there.” Did not proceed with trauma processing. Shifted to 5-4-3-2-1 grounding exercise; client returned to window of tolerance within approximately 10 minutes. Remainder of session focused on stabilization and psychoeducation on the nervous system response. Client left session regulated.

The Assessment section in trauma-informed notes

The most important question in a trauma assessment is: where is this client in their stabilization, and is that where they need to be before going further?

Many clients want to get to the trauma material quickly. They are tired of not talking about it. They mistake the intensity of their emotional response for readiness. Part of your clinical job is being honest in your notes about the gap between a client’s expressed readiness and their actual nervous system capacity. That gap is the clinical picture. Your assessment should name it directly.

DAP note example: trauma-informed assessment section

Client’s activation level indicates stabilization phase is not yet complete, despite her expressed readiness to begin processing. Dissociative markers appeared for the first time in four sessions, suggesting that increased discussion of the incident in recent weeks may be activating before adequate resourcing is in place. Grounding skills are present but access under activation remains inconsistent. Return to explicit stabilization work is clinically indicated before proceeding. Will discuss this with client at the start of next session to maintain transparency and reinforce her sense of agency in pacing.

The Plan section in trauma-informed notes

Trauma plans should be specific about phase and pacing. “Will continue trauma-informed work” tells me nothing. State where you are in the treatment model, what you will do if the client presents activated at the start of next session, and what the threshold is for moving toward processing versus pulling back to stabilization.

DAP note example: trauma-informed plan section

Will return to explicit stabilization work next session. Will introduce container visualization before revisiting any trauma material. Will have a direct conversation with client about what her nervous system is showing us and why pacing matters, framing this as collaboration rather than withholding. Will reassess activation levels and dissociative markers across the next two sessions before reconsidering readiness for processing. Client encouraged to practice grounding techniques daily. Will not introduce new trauma content until client demonstrates consistent return to window of tolerance within five minutes during resourcing practice.

Best Practices for Writing DAP Notes Across All Modalities

These are the patterns that show up in strong clinical documentation regardless of which modality you are working in. They are not formatting tips. They are ways of thinking about your notes that change the quality of everything you write.

The Assessment section should be the hardest part to write

If your Assessment takes you 30 seconds, something is wrong. Not because you need to be slow, but because clinical thinking takes effort. The clients who are easiest to write assessments for are usually the ones we have stopped really looking at.

Specificity protects you and your client

Vague notes feel safer. They are not. “Client reported distress” gives you nothing to stand on if your care is reviewed. “Client reported urges to self-harm at 6/10, denied intent, identified her sister as a support, and verbally committed to calling the crisis line before acting” gives you a clear record of what you assessed and what you did. Specificity is not just good practice. It is a professional obligation.

Avoid the summary trap

The summary trap is when your note becomes a narrative account of the session rather than a clinical record of what you observed, assessed, and decided. A note that starts with “Client discussed…” and runs for three paragraphs shows you were present. It does not show you were working.

Your notes should connect session to session

If a colleague picked up your caseload tomorrow and read your last five notes, they should understand exactly where this client is in treatment, what has been tried, and what has worked. If your notes do not give them that picture, they are not doing their job as clinical documentation. Each note should be a chapter, not a standalone story.

Document clinical decisions, not just clinical actions

There is a difference between writing “used grounding technique” and “shifted to grounding when client showed dissociative markers, delaying trauma processing to protect stabilization gains.” The second version shows a clinician thinking in real time. The best client assessments in any framework capture that active decision-making, not just the outcome.

Connect every note to the treatment plan

Every session should connect, at least implicitly, to the client’s documented treatment goals. If your notes consistently describe sessions that feel disconnected from the treatment plan, that is a signal that either the plan needs updating or the notes need to be more explicit about the connection.

Mistakes to Avoid in DAP Notes

Writing the same note every session

If your notes from session four and session fourteen are interchangeable, you are not documenting treatment. You are documenting that sessions occurred. Boilerplate is a liability, not a time-saver.

Burying the risk data

In any note where self-harm, suicidal ideation, or significant instability is present, that information should not be buried in the middle of a paragraph. It should be visible, specific, and followed immediately by what you did about it.

Writing the Assessment as a restatement of the Data

“Client reported anxiety at work. Client continues to experience anxiety.” That is not interpretation. Pull the data into the assessment and say something new with it. What does the pattern tell you? What has changed or not changed? Where does it fit in the treatment arc?

Documenting trauma content instead of trauma process

In trauma-informed practice, what the client disclosed is far less important to document than your clinical response to it and why. If a record is ever reviewed outside the therapeutic relationship, the reader needs to know you were tracking the nervous system, pacing appropriately, and making sound decisions. Document that. Not the disclosure content.

Using the Plan section as a calendar

“Next session in one week” is not a plan. The plan is a clinical statement of intent. Where are you going? What are the decision points? What would cause you to change course?

Writing only one sentence in the Assessment

The assessment is the heart of the clinical note. A one-sentence assessment like “client is making progress” gives almost no clinical information. Even two or three detailed sentences is far better than a placeholder that could apply to any client on any day.

Final Thoughts

The best progress notes are written by clinicians who treat documentation as part

The best progress notes I have ever read were written by clinicians who treated documentation as part of their clinical practice, not separate from it. They used the act of writing to clarify their own thinking. They noticed when they could not articulate their assessment clearly and took that as a signal to think harder about what was actually happening with their client.

A strong DAP notes template is not a form to fill out. It is a structure that holds your clinical thinking across time.

CBT notes should be specific, skill-anchored, and tied to measurable movement.
DBT notes should track risk with precision and reflect the treatment model at every level.
Trauma-informed notes should document process over content and nervous system state over surface affect.

And across all three, the best practices for writing DAP notes come down to one thing: write as if the note is part of the treatment, not just a record that treatment happened.

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What Physicians Need to Know About CMS’s 2027 Coding and Documentation Overhaul

omni — Wed, 08 Apr 2026 11:29:56 +0000

What Physicians Need to Know About CMS’s 2027 Coding and Documentation Overhaul

What do the CMS coding and documentation changes mean for physicians?

CMS is tightening how diagnoses are documented, coded, and valued in risk adjustment models. This means providers must capture more precise clinical details in their notes to ensure accurate reimbursement. Incomplete or vague documentation may lead to lower risk scores, reduced payments, and increased audit scrutiny. To stay compliant and financially stable, practices must improve documentation accuracy, align coding with clinical evidence, and adopt tools that support real-time, structured charting.

CMS is tightening the rules on how risk gets measured, how diagnoses get valued, and how much scrutiny your documentation will face. Here is what that means for your practice, your patients, and your notes.

If you have been sensing that the documentation pressure in your practice is getting heavier, you are not imagining it. A policy shift is underway at CMS that will directly change how your clinical notes are interpreted, how the diagnoses you record are weighted financially, and how much scrutiny the codes you submit will face. Understanding what is driving that shift, and why it is arriving now, is the starting point for responding to it intelligently.

“The art of medicine consists in amusing the patient while nature cures the disease. But in 2027, the art will also consist in documenting what nature is dealing with, precisely enough to survive a risk model audit.”

Adapted from Voltaire, with a 21st-century addendum

The Policy Signal Behind the 2027 Advance Notice

The CMS 2027 Advance Notic, released January 26, 2026, is more than an actuarial filing. It is a policy declaration. CMS has stated plainly that it believes the 2027 changes will address coding differentials between Medicare Advantage and Original Medicare. That phrase, nested in the opening letter from Center for Medicare director Chris Klomp, is carrying enormous weight.

What CMS is describing is a known, documented, persistent gap between how conditions get coded in Medicare Advantage (MA) versus traditional fee-for-service. As practices transition into value-based care models, understanding this shift is the starting point for responding to it intelligently.

MA plans have historically captured more diagnoses per patient, generating higher risk scores and therefore higher capitation payments. CMS has watched this gap for years.

In 2027, it is doing something about it at the model level, and the effects will flow directly into how physician documentation is interpreted, weighted, and financially valued.

4.04%

Projected MA per capita growth rate for 2027 (aged + disabled)

5.39%

Underlying per capita cost trend driving that growth

6.17%

Per capita growth for ESRD dialysis patients-the most complex tier

That is why this notice matters to clinicians because the decisions being made in this filing will determine what a well-documented note is worth, and what an imprecise one costs.

Why These Changes Land Hard: The Cost Trajectory Behind the Model

To understand why these model changes carry such consequence, it helps to look at where Medicare costs are already headed, because the patients who will be most affected by tighter documentation standards are the same ones whose care is growing most expensive.

Medicare’s sickest patients are getting more expensive to care for, faster than inflation and faster than overall program growth. ESRD patients alone are on a 6.17% per capita annual cost trajectory. These are also the patients whose documentation requires the most precision, and whose care will be most affected by what happens next in the risk model.

In other words, the patients who demand the most clinical attention are also the ones where documentation errors carry the greatest financial consequence. That intersection is where the 2027 changes will hit hardest.

Risk Adjustment: The CMS-HCC model is being retightened. Here is what that demands from your notes.

The CMS-HCC risk adjustment model is the engine that converts diagnoses in a patient’s record into a risk score, which in turn determines how much a plan is paid per enrollee. When the model is calibrated generously, imprecise documentation can still produce a usable code. When it is calibrated tightly, only specificity survives. Achieving this level of HCC coding accuracy is what the V28 updates demand from your clinical notes. The 2027 Advance Notice signals a clear move toward the latter.

The notice outlines updates to the V28 version of this model, including revised relative factors across population categories: continuing enrollees, aged and disabled new enrollees, and new enrollees in Chronic Condition Special Needs Plans.

The direction of recalibration matters deeply. The model is being tuned against how patients actually use resources in fee-for-service settings, not against the historically elevated coding patterns observed in MA. That means certain HCCs that have been weighted generously will carry lower relative factors going forward, and conditions that are real but documented imprecisely may not register at all.

“Measure what is measurable, and make measurable what is not so.”

Galileo Galilei- a principle CMS is now applying to diagnosis codes

How Physician Documentation Flows Into Risk-Adjusted Payment

The model is not being redesigned to punish physicians. It is being redesigned to reward accuracy. But that switch puts the burden squarely on the clinical note. Here is what that looks like condition by condition:

Diabetes: “Diabetes with complications” and “diabetes without complications” map to different HCCs.Following a structured guide for ICD-10 codes for diabetes ensures the difference lives clearly in your documentation.
Heart failure: Staging, functional class, and etiology all affect how the condition maps. “CHF” alone is not sufficient in a tighter model.
CKD: Stage matters. Stating the stage once per year, with clinical basis in the note, is what keeps it active in the risk calculation.
ESRD: With a 6.17% per capita cost growth trajectory, these patients represent the highest documentation stakes in your panel.
Mental health comorbidities: Often under-documented in primary care despite being active clinical problems that carry real HCC weight.

CMS is filtering its own data for anomalous billing. That should tell you something.

However, the model recalibration is not the only lever CMS is pulling. It is also cleaning up the data it uses to set payment benchmarks, and the way it is doing that sends a clear message about where documentation standards are heading.

One of the less-noticed provisions in the 2027 Advance Notice is a proposed exclusion of significant, anomalous, and highly suspect billing activity in Calendar Years 2023 and 2024 from the ratebook fee-for-service experience.

CMS is building a cleaner dataset by removing billing it considers implausible before using that data to set payment benchmarks.

“In God we trust; all others must bring data. And in 2027, CMS is very specifically deciding which data it trusts.”

W. Edwards Deming, adapted for the modern era of risk adjustment

What this signals for physicians

When a regulatory agency starts explicitly filtering its own datasets for anomalous patterns, it is communicating that it has built the analytical infrastructure to find outliers. The question every physician should be asking is not whether their individual billing is problematic, but whether their documentation would hold up to the kind of scrutiny that is now being applied at the model level. The answer to that question depends entirely on what is in the chart.

What this signals is a change in what “good documentation” means going forward. The old posture was additive, capturing everything that could generate a code. The new posture has to be defensible, every code backed by clinical evidence that would survive scrutiny. Preparing your practice for surviving a medical billing audit is now a core requirement of the 2027 environment.

Physicians who care for the most complex patients, the ones with ESRD, overlapping chronic conditions, active mental health comorbidities, face the steepest documentation requirements at the exact same moment those patients demand the most clinical attention. Which raises the practical question: how are physicians actually supposed to do this?

AI Scribes and the JAMA Study: What the Numbers Really Mean

That question, how to meet a rising documentation standard without sacrificing clinical presence, is exactly what a landmark study published in JAMA in April 2026 was designed to answer.

The study, co-led by researchers from Mass General Brigham and UCSF, covered five academic health systems, tracked over 8,500 ambulatory clinicians for more than two years, and compared 1,809 AI scribe adopters against 6,770 control clinicians at the same institutions.

13 min

Daily reduction in total EHR time per 8 scheduled patient hours

16 min

Daily reduction in documentation time specifically (10% relative decrease)

0.5

Additional patient visits per week among AI scribe adopters

The headline findings, 13 minutes of saved EHR time per day, 16 minutes of documentation time, half a visit per week, have been met with underwhelmed commentary in some corners of medicine. That reaction is understandable, but it misses where the real value is.

“We do not rise to the level of our expectations. We fall to the level of our tools. The question for 2027 is which tools physicians choose to fall back on.“

Archilochus, interpreted for the documentation era

The more important finding is what happened among clinicians who used AI scribes for 50% or more of their visits.

Power users, those who applied the tool consistently, experienced over twice the reduction in total EHR time and three times the reduction in documentation time. The technology has a utilization ceiling problem, not a capability problem. Implementing a purpose-built AI medical scribe for clinicians is the most direct way to cross the threshold where benefits become meaningfully larger. Only 32% of adopters crossed the threshold where the benefits became meaningfully larger.

WHO BENEFITED MOST

The most pronounced improvements were observed among primary care physicians, advanced practice providers, and female clinicians. Primary care is precisely where the HCC documentation burden concentrates, because that is where chronic condition capture happens annually, where the diagnoses that feed the risk model get refreshed, and where the coding differential CMS is trying to close has historically been most significant.

Why the $167 Monthly Revenue Figure Is the Wrong Number to Lead With

Media coverage of the JAMA study led with the $167 monthly revenue finding, which frames the value of AI scribes entirely through a throughput lens. But in a 2027 payment environment, throughput is not the point.

THROUGHPUT FRAMING (WRONG LENS)

Can I see 0.5 more patients per week?
Will I earn $167 more per month?
Is the ROI positive on the subscription cost?

DOCUMENTATION QUALITY FRAMING (RIGHT LENS)

Are my chronic condition diagnoses captured annually with specificity?
Is the clinical basis for each HCC-relevant code present in the note?
Would my documentation survive the scrutiny CMS is now building into its models?

The freed cognitive bandwidth during a visit is not best measured in additional appointments scheduled. It is best measured in whether a physician, no longer mentally composing a note while examining a patient, captures the nuanced clinical picture that the 2027 HCC model will require.

The study authors noted that clinicians may be reallocating their recovered time into reviewing prior documentation, responding to patient messages, and spending more face-to-face time in the room. Each of those activities directly feeds the quality of the clinical record, which is exactly what the 2027 model is designed to reward.

“The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease.”

Thomas Edison-who also understood that the right tool changes what is possible

What this means by role

The 2027 changes do not land the same way for every clinician. Here is where the stakes are sharpest by role:

Primary care physicians: The annual chronic condition documentation that feeds HCC scoring happens in your office. Using specialized primary care EHR software ensures that precision becomes a natural part of your workflow. The 2027 model updates make precision there more consequential than ever.
Specialists: Conditions you document, even in consultation notes, can contribute to a patient’s MA risk score. Specificity in your notes matters across the care continuum.
Advanced practice providers: The JAMA study found APPs among those who benefited most from AI scribe adoption. The documentation burden on APPs in primary care is proportionally higher — and so is the upside of addressing it.
Medical directors and CMOs: The 2027 changes create a practice-level incentive to invest in documentation infrastructure now, before the rate announcement finalizes in April 2026.

The Bottom Line: CMS Wants the Model to Be Honest. The Burden of That Honesty Falls on the Chart.

CMS’s goal is not to make medicine harder. It is to make the payment model reflect clinical reality more accurately. That is a defensible objective. But the practical effect of pursuing it through model recalibration, differential adjustments, and anomalous billing exclusions is that the documentation bar rises most steeply for the physicians who care for the most complex patients.

Those two pressures, document more precisely, while caring for patients who demand more of your attention, do not have to be in conflict. But resolving them requires more than a coding strategy or a compliance checklist.

If the 2027 overhaul pressures physicians to document more precisely while they are already stretched thin, and if AI scribes offer a real, evidenced, but underutilized path toward recovering some of that cognitive capacity, then the most consequential decision many physicians can make in the next twelve months is not about coding. It is about whether they are willing to actually adopt an AI medical coding solution that could make the precision CMS is demanding feel less like a regulatory burden.

CMS is asking for documentation that reflects clinical truth. The JAMA study is showing that there are tools available to help physicians deliver it without burning out. The gap between those two facts is not regulatory. It is a utilization gap, a behavioral gap, a decision that will be made practice by practice, physician by physician, in the months before the 2027 rate announcement finalizes. The physicians who close that gap first will not just be better positioned for 2027. They will be better physicians for their most vulnerable patients, which was the point all along.

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Telehealth Reimbursement 2026: What Providers Need to Know

omni — Mon, 06 Apr 2026 12:49:45 +0000

Telehealth Reimbursement 2026: What Providers Need to Know

When providers think about billing problems, they usually think about denied claims, and that makes sense because a denial is visible. It shows up in the system, someone has to act on it, and there is at least a chance it gets corrected.

But the more costly and more common problem in telehealth reimbursement is not the denial. It is the claim that processes and pays, just at a lower rate than it should, with nothing to flag it as wrong.

This kind of underpayment is almost impossible to catch unless you are actively comparing what you received against what you were supposed to receive, which most practices do not do routinely.

The result is that a practice can be running what looks like a healthy telehealth program, with claims going out and payments coming in, while losing a meaningful amount of revenue every single week on visits that were billed correctly in almost every way except one small detail that the payer used to justify a lower rate.

Understanding where that detail tends to go wrong is the first step to stopping it.

The second thing worth knowing upfront is that the 2026 rule changes from CMS are genuinely significant for some practices, not because they make billing harder but because they opened up billing opportunities that many practices have not yet acted on.

Services that used to have strict frequency limits can now be billed more often.

Visit types that were previously excluded from telehealth coverage are now included.

Providers who have not looked at the updated rules are almost certainly missing revenue that is already sitting there, attached to work they are already doing. Both of those things, fixing the losses and capturing the new opportunities, are what this blog covers.

Why You Are Probably Being Underpaid On Home-Based Visits

The single most common source of telehealth underpayment comes down to a two-digit code called the place of service code, and the reason it matters is something most providers were never explicitly told.

When you bill Medicare for a telehealth visit, one of the things you have to specify is where the patient was sitting during the call. Not where you were. Where they were.

Medicare telehealth reimbursement uses POS 10 for visits where the patient was at home, and POS 02 for visits where the patient was somewhere other than home, like a clinic, workplace, or any other non-residential location.

The reason this distinction affects your payment is that Medicare calculates telehealth reimbursement rates differently depending on which code applies.

POS 10 triggers what Medicare calls the non-facility rate, which in most cases is higher than what POS 02 produces.

Here is what makes this particularly easy to miss: using the wrong code does not produce a denial. It produces a payment, just a smaller one, and because the payment comes through without an error message, there is nothing in the normal billing workflow to catch it.

A practice that has been defaulting to POS 02 for all telehealth visits, which is common because POS 02 was the standard telehealth code before pandemic-era billing became normalized, is receiving less than it is owed on every single home-based visit, Modern medical billing software can prevent these quiet losses by automatically validating the Place of Service code against the patient’s registered home address before the claim is even generated.

The reason POS errors are so persistent is that the patient’s location is not being captured anywhere in the visit workflow, so when the claim is being built, the biller has to guess or default to habit.

The fix is as simple as adding one question to your telehealth check-in process. Before every visit, whoever is checking the patient in asks where they are calling from and records the answer. When using a fully integrated EHR workflow, that answer flows into the claim as the correct POS code, and the underpayment problem stops.

Practices that implement this and then go back and look at six months of prior claims frequently find that the rate difference across hundreds of visits adds up to a number that is hard to look at.

The place of service code also matters because it is connected to telehealth modifiers, which are the small codes you add to a claim to flag that the visit happened remotely. Understanding proper telemedicine billing and coding means recognizing that a lot of billing teams treat the modifier as the critical telehealth billing detail, but the modifier only does its job when the rest of the claim, including the POS code, is accurate. A modifier on a claim with the wrong POS does not rescue the payment. It just adds a second thing the payer can point to when explaining why the rate was calculated the way it was.

Audio-Only Behavioral Health Visits: Billable, But Almost Never Documented Right

There is a widespread assumption among behavioral health providers that if a patient calls in by phone instead of joining a video session, the visit cannot be billed. Some practices do not submit claims for those visits at all.

Others write them off as a courtesy. Both responses are leaving real money uncollected, because Medicare explicitly allows audio-only billing for mental health and behavioral health under specific conditions, and those conditions are met by a large share of behavioral health patients on a regular basis.

The conditions are straightforward.

The patient needs to be at home during the call, and video needs to have been either not technically available to them or something the patient chose not to use.

A patient without reliable internet qualifies.
A patient calling from a room they share with other people, where a video call would not be private, qualifies.
A patient who simply prefers talking by phone and has expressed that preference qualifies.

These are not unusual situations in behavioral health. They describe a significant portion of the patient population that many practices serve every day, and the visits with those patients are fully billable under Medicare when the documentation reflects the circumstances.

The documentation is where almost every audio-only claim problem originates. It is not that providers are trying to bill for visits that do not qualify. It is that the chart note from a phone visit typically says nothing specific about the modality or the patient’s situation, because the documentation template was built for video visits and nobody ever updated it for audio-only. Utilizing specialty-specific Mental health EHR templates ensures these prompts are baked into the clinical note automatically

When a payer reviews one of those claims, they are looking for three specific things:

Confirmation that the patient was at home
A notation that the visit was audio-only, and
A brief explanation of why there was no video.

If none of those things appear in the note, the claim gets flagged on audit and often clawed back, even when the visit itself was completely appropriate and the telehealth CPT codes were correct.

Updating a documentation template to prompt for those three things takes a few minutes. Once it is in place, every audio-only note automatically captures what the payer needs to see, and the risk of a claw-back on a legitimate visit drops to almost nothing.

The practices that have done this and then looked at their prior audio-only claims often find a pattern of valid visits that were billed correctly but documented in a way that made them look like they were not.

For Medicaid patients, audio-only billing gets more complicated because telehealth insurance reimbursement rules vary by state and, within each state, by managed care plan.

A state Medicaid office might explicitly allow audio-only billing for behavioral health, but a managed care organization operating under that state’s Medicaid contract can set its own more restrictive policy on top of that.

So it is entirely possible for the same type of visit to be covered under the state policy and denied by a specific plan in that same state, and this is not a rare exception.

It is a routine source of denials for behavioral health practices that see Medicaid patients across multiple managed care plans.

Verifying audio-only coverage at the plan level, not just the state level, is the only way to know for certain what will actually get paid.

The Medicaid Document You Are Checking is Probably Not the One That Governs Payment

This is the Medicaid issue that catches the most practices off guard, and it stems from a reasonable but incorrect assumption about how Medicaid works.

When a provider wants to know whether a telehealth service is covered for a Medicaid patient, the natural thing to do is check the state Medicaid telehealth policy. That policy document describes what the state’s Medicaid program covers, and it is usually publicly available and fairly easy to find.

The problem is that for the majority of Medicaid patients, the state policy is not what actually governs their coverage.

Most Medicaid patients are enrolled in managed care organizations, which are private insurance companies that states contract with to administer their Medicaid programs.

Those managed care organizations have their own contracts with providers and their own telehealth reimbursement policies, and those policies are negotiated separately from the state Medicaid policy.

Under federal rules, managed care plans cannot cover less than what federal Medicaid requires, but they can cover less than what the state’s own Medicaid policy allows, and they frequently do.

The result is that a service can be clearly covered in the state Medicaid telehealth policy and still be denied by a managed care plan operating under that same state program, because the plan has drawn its own lines around what it will reimburse.

This creates a situation where checking the state policy gives you a false sense of security. You confirm the service is covered, you bill it, the claim gets denied, and the denial reason points to the plan’s internal policy rather than anything in the state’s published rules.

This happens routinely in practices that see Medicaid patients across multiple managed care plans, and the only way around it is to verify coverage at the plan level for each managed care organization you work with, which means getting the actual telehealth policy document from each plan and comparing it to what you are billing.

That verification also needs to happen periodically rather than once, because managed care contracts renew and telehealth policies within them change, sometimes without any formal notice to providers.

The broader issue with Medicaid is that variation goes deeper than most providers expect. It is not just that states differ on whether telehealth is covered.

Within a single state, the covered services, the eligible provider types, the allowed locations, and the payment rates can all be set differently depending on the plan and the contract.

A psychiatrist billing telehealth under one managed care plan may operate under completely different rules than a social worker billing the same visit type under a different plan in the same state.

Treating Medicaid as a uniform system with state-level rules is the assumption that produces the most persistent and hardest-to-diagnose billing problems in telehealth. For many practices, the most cost-effective way to manage this complexity is through expert medical billing services that perform plan-level verification on every claim.

New Jersey’s Parity Deadline And What the Commercial Rate Question Looks Like Everywhere Else

Commercial insurance adds a different kind of complexity to telehealth billing guidelines because the rate you get paid for a telehealth visit is not just a function of what you billed. It depends on whether your state requires commercial insurers to pay the same rate for telehealth as they do for in-person visits, and on what your specific contract with each payer actually says.

In states with strong telehealth parity laws, providers can count on telehealth rates matching in-person rates for the same services. In states without those laws, payers are free to set lower telehealth rates in their contracts, and many do.

New Jersey is a particularly important example right now because the state’s current parity requirement, which mandates that commercial plans reimburse covered telehealth services at the same rate as in-person services, expires on July 1, 2026.

If the state legislature does not extend it before that date, commercial plans in New Jersey will be legally free to begin paying lower rates for telehealth in the second half of the year.

For providers in New Jersey whose telehealth volume is significant, this is not an abstract policy issue. It is a specific date after which revenue from commercial telehealth could decrease, and the time to understand what that means for the practice’s finances is before July, not after the first set of remittances comes back at a lower rate and nobody knows why.

Even outside New Jersey, and even in states with active parity laws, the rate question is worth checking directly rather than assuming.

Parity laws vary in what they actually require: some mandate rate parity, meaning the same dollar amount for the same service. Others require only coverage parity, meaning the service must be covered but the rate can still differ.

Many parity laws apply only to fully insured plans and not to self-funded employer plans, which are governed by federal ERISA rules rather than state insurance law. A practice in a parity state whose patients are mostly on self-funded employer plans may have far less rate protection than it thinks.

The simplest check is to pull the telehealth rate and the in-person rate for the same telehealth CPT codes from the fee schedule of each major commercial payer and compare them side by side.

If there is a gap that the parity law should be closing, that is worth raising directly with the payer as a contract conversation. If there is a gap in a state without parity protections, knowing its size helps the practice make informed decisions about telehealth volume rather than discovering the discrepancy buried in a remittance report months after the fact.

The 2026 Rule Changes That Most Practices Have Not Acted On Yet

The CMS telehealth guidelines for 2026 are worth going through specifically rather than generally, because the ones that matter most for practice revenue are the kind that do not make headlines but quietly create billing opportunities for providers who know to look for them.

The most significant change for many practices is the permanent removal of frequency restrictions on certain telehealth service types.

Before 2026, there were hard limits on how often some telehealth visit types could be billed, even when the clinical situation clearly warranted more visits. Those limits have now been removed for specific categories, including certain subsequent visit codes for patients in inpatient and nursing facility settings and certain critical care consultation codes.

For practices that see patients in those settings via telehealth, this means visit types that previously hit a billing ceiling can now be billed as often as clinically appropriate.

If your billing process was built around the old frequency limits and nobody updated it after the 2026 rule took effect, you may be capping your own billing on visits where no cap is required anymore.

Checking the current CMS telehealth services list against what your practice actually bills, specifically looking for service types with removed frequency limits, is a straightforward way to find revenue that is already attached to work you are doing.

The other significant change is the recognition of virtual direct supervision for selected services when both audio and video are live during the session.

Direct supervision previously required the supervising provider to be physically present in the same location as the clinical staff member performing the service.

That requirement has been relaxed for certain services, meaning practices can now deliver some supervised services via telehealth that previously required the supervisor to be on-site.

This is particularly relevant for practices that use supervised clinical staff across multiple locations, because it removes a logistical constraint that was limiting how those practices could structure their telehealth delivery. With a compliant telehealth platform, providers can now easily manage virtual direct supervision while staying within 2026 guidelines.

What To Do, In The Order That Recovers Money Fastest

Pull the last 90 days of telehealth claims and compare your telehealth reimbursement rates against your in-person rates for the same CPT codes, payer by payer, because if POS 02 has been used instead of POS 10 for home-based visits, the gap will show up here and tell you exactly how much has been left on the table across every affected claim.

Add patient location to your telehealth check-in so that before every visit, the patient confirms whether they are at home or somewhere else, and that answer flows directly into the POS code on the claim rather than being filled in by the biller from habit or assumption.

Update your behavioral health documentation template to prompt for patient location, modality, and a brief reason video was not used. If manual updates are too burdensome, consider how an AI medical scribe can capture these specific telehealth details during the conversation to ensure audit-proof notes.

Get the telehealth coverage policy document from each Medicaid managed care plan you bill and compare it against what you are actually submitting, paying particular attention to any service types where the plan policy is more restrictive than the state Medicaid policy, since that gap is where the most common and least visible Medicaid denials come from.

If you are in New Jersey, model your commercial telehealth revenue under a scenario where parity expires on July 1, 2026 and rates drop to whatever your contract allows without the parity requirement, so that if the legislature does not extend the law you already know what it means for your numbers and are not making reactive decisions in the middle of a billing cycle.

Review the updated CMS telehealth services list specifically for service types that had frequency restrictions removed in 2026, and check whether those apply to visits your practice is already doing, because this is the most direct way to add billing revenue without adding any clinical work or changing any existing processes.

Set a monthly reminder to review a random sample of about 10 percent of telehealth claims as part of your broader telehealth revenue cycle management process, checking that the POS code, modifier, and documentation basics are all present and correct, because the errors that cost the most money in telehealth reimbursement are almost always systematic rather than random, and catching them after one month costs a fraction of what catching them after six months does.

Frequently Asked Questions

My telehealth claims are getting paid, so how would I know if I am being underpaid?

A paid claim and a correctly paid claim are not the same thing, and the difference is only visible if you compare what you received against what you should have received for each service under each payer. The most common source of quiet underpayment is the POS code: if POS 02 is being used for visits where the patient was at home, the claim pays at a lower rate and nothing flags it as an error. Pulling your telehealth reimbursement rates and your in-person rates for the same CPT codes from your fee schedule and comparing them side by side is the quickest way to see whether a gap exists.

What exactly does Medicare need in the chart note to pay an audio-only behavioral health visit?

Three things that need to be explicitly present in the note: confirmation that the patient was at home during the visit, a statement that the modality was audio-only rather than video, and a brief explanation of why video was not used, whether the patient lacked access to it, did not have a private space, or chose not to use it. None of those need to be lengthy, but all three need to be present, because a reviewer treating their absence as equivalent to the visit not meeting the criteria is exactly what produces claw-backs on visits that were clinically appropriate and correctly billed. Meeting telehealth billing requirements at the documentation level is just as important as using the correct codes.

Why would a Medicaid telehealth claim get denied when the state policy says it is covered?

Because the state Medicaid policy and the managed care plan policy are different documents, and the managed care plan policy is what governs payment for most Medicaid patients. Managed care plans can set coverage rules that are more restrictive than the state’s own policy, and they frequently do. Confirming coverage with the state Medicaid office tells you what the maximum allowed coverage is. It does not tell you what a specific managed care plan will actually reimburse, which is why plan-level verification is the only reliable check.

What is the New Jersey parity deadline and what happens if it expires?

New Jersey currently requires commercial insurance plans to reimburse covered telehealth insurance reimbursement at the same rate as in-person services. That requirement expires on July 1, 2026. If the state does not extend it, commercial plans in New Jersey will be free to pay lower rates for telehealth after that date, with the exact rate determined by individual payer contracts rather than a state mandate. The practical impact depends on how much of a practice’s revenue comes from commercial telehealth and what the contracted telehealth rates look like without the parity floor.

What specific services can now be billed more often under the 2026 CMS changes?

CMS permanently removed frequency restrictions on certain subsequent visit codes for patients in inpatient and nursing facility settings and on certain critical care consultation codes. These service types previously had hard billing limits that applied regardless of clinical need. Those limits no longer exist for the affected codes, meaning they can now be billed as often as clinically appropriate. The exact list is in the 2026 CMS telehealth services document, and comparing it against your current billing process is the most direct way to identify whether any of the changes apply to visits your practice is already doing.

What is the difference between the place of service code and the telehealth modifier, and does the order they are applied matter?

The place of service code tells Medicare where the patient was, which affects the payment rate. The telehealth modifier tells Medicare the visit happened remotely, which identifies it as a telehealth claim. Both are required under standard telehealth billing requirements, and they serve different purposes. The order does not matter, but their accuracy relative to each other does: a modifier on a claim with the wrong POS code does not fix the rate problem, it just means the claim has two things that are inconsistent with each other, which payers can use to justify processing at the lower rate.

How do I know whether my state’s parity law actually covers all my commercial patients?

Most state parity laws apply only to fully insured plans, meaning plans where the employer purchases coverage from an insurance company. They generally do not apply to self-funded plans, where the employer pays claims directly and simply uses an insurance company for administration. Self-funded plans are governed by federal ERISA law rather than state insurance law, which means state parity requirements do not reach them. If a significant portion of your commercially insured patients are on employer plans from large companies, there is a good chance many of those plans are self-funded and outside your state’s parity protection, regardless of how strong that protection is.

Is a monthly claim audit actually worth the time for a small practice?

For most practices, yes, specifically because the errors that cost the most money in telehealth reimbursement tend to be systematic rather than random. A single wrong default in the billing workflow can affect every claim it touches, and the longer it runs undetected the more expensive it becomes to recover from. Reviewing 10 percent of claims once a month takes under an hour in most practices and catches those systematic errors while they are still small. Strong telehealth revenue cycle management means building that habit in before problems compound. The alternative, discovering six months of the same mistake at once, is both more expensive and harder to correct because many payers have strict timelines for claim corrections and appeals.

Do I need different billing codes for telehealth versus in-person visits?

Generally no. The same CPT codes that apply to in-person visits apply to telehealth visits of the same type. What changes is the place of service code, the telehealth modifier, and the need to confirm that the specific service is on the payer’s covered telehealth list. Understanding telemedicine billing and coding comes down to recognizing that the visit code itself stays the same. The context codes around it are what make it a telehealth claim and what the payer uses to determine the applicable rate.

What is the fastest way to find out if my practice has a systematic billing error right now?

Pull the last 90 days of telehealth claims, filter by denial reason, and look for whatever denial reason appears most often. A denial reason that shows up across many claims is almost always a workflow issue rather than a series of individual mistakes, and identifying it takes minutes. For underpayment rather than denials, the equivalent check is comparing telehealth rates against in-person rates for the same CPT codes across your major payers. Either check takes less than an hour and, in most practices, surfaces at least one thing that has been quietly costing money for longer than anyone realized.

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Navigating Value-Based Care: What Small Practices Must Do

omni — Mon, 06 Apr 2026 11:22:49 +0000

Navigating Value-Based Care: What Small Practices Must Do

The U.S. healthcare system is going through a major transformation. Traditional fee-for-service models, which reward the number of services delivered, are gradually being replaced by value-based care. In this model, healthcare providers are rewarded for improving patient outcomes while delivering care more efficiently.

For many physicians, especially those running independent or small practices, this change can feel overwhelming. The transition to value-based care introduces new performance metrics, reporting requirements, and operational changes that smaller organizations may not always be fully prepared for.

At OmniMD, we work closely with practices navigating this shift every day. From the experience we have gained, we know that while the transition can be complex, small practices can absolutely succeed in value-based care for small practices, provided they adopt the right strategies, workflows, and technologies.

Understanding how value-based care works and what steps practices should take or follow, can make this transition far more manageable.

Understanding Value-Based Care

Value-based care is a healthcare delivery and payment model that focuses on improving patient outcomes, care quality, and cost efficiency rather than simply increasing the number of services performed.

In traditional fee-for-service healthcare, providers are reimbursed for each visit, test, or procedure. While this model has been the standard for decades, it often encourages higher service volume rather than better patient outcomes.

By contrast, value-based reimbursement models evaluate providers based on measurable results such as improved patient health, reduced hospital readmissions, and higher patient satisfaction.

Government programs have accelerated this shift. The Quality Payment Program (QPP), which includes MIPS (Merit-Based Incentive Payment System) and Alternative Payment Models (APMs), encourages providers to focus on delivering higher-quality and more coordinated care.

Why Value-Based Care Matters for Small Practices

This shift toward value-based reimbursement is not just a policy shift, it is becoming the new standard of healthcare delivery very quickly.

Organizations such as CMS aim to significantly expand value-based payment models in the coming years by encouraging providers to focus on patient-centered care, preventive health, and coordinated treatment strategies.

For small practices, this transformation creates both opportunities and challenges.

Opportunities

Higher reimbursement for high quality care
Improved patient engagement and satisfaction
Long term financial stability through quality incentives

Challenges

Limited administrative resources
Complex reporting requirements for programs like MIPS
The need for advanced healthcare technology and analytics

Despite these hurdles, many independent practices are successfully adapting by transforming their clinical and operational strategies.

Key Challenges in the Transition to Value-Based Care

The transition often requires a fundamental shift in how practices operate.

Data and Reporting Requirements

Programs such as MIPS require providers to track and report quality measures, performance metrics, and patient outcomes. Without the right infrastructure, this can become a significant administrative burden.

Technology Gaps

Small practices frequently struggle with implementing systems that support population health management, interoperability, and quality reporting.

Care Coordination

Under value-based care models, providers must ensure that patients receive coordinated treatment across multiple care settings. This requires better communication between physicians, specialists, and care teams.

Financial Risk

Some alternative payment models (APMs) introduce performance-based incentives or penalties, which can create financial uncertainty for smaller organizations.

What Small Practices Must Do to Succeed

While the shift to value-based care for small practices can feel daunting, several practical strategies can help practices adapt successfully.

1. Invest in Data-Driven Healthcare Technology

Technology plays a key role in managing value-based care programs. Practices need systems that can track quality metrics, manage patient data, and simplify reporting requirements.

A modern EHR designed for value-based care can help automate data collection, support regulatory reporting, and provide insights that improve patient outcomes.

2. Focus on Preventive and Population Health

Preventive care is one of the core principles of value-based reimbursement models. Practices should prioritize:

Chronic disease management
Preventive screenings
Patient education and engagement

These strategies do not only improve patient outcomes but also help in minimising costly hospitalizations and emergency visits.

3. Strengthen Care Coordination

In a value-based healthcare environment, collaboration between providers is essential.

Practices should establish workflows that improve communication between:

Primary care physicians
Specialists
Care coordinators
Community health resources

Better care coordination in healthcare leads to improved patient outcomes and higher quality scores.

4. Streamline Clinical and Administrative Workflows

Operational efficiency is critical when participating in programs like MIPS and alternative payment models.

Practices should focus on:

Streamlining documentation
Automating quality reporting
Reducing administrative overhead

Efficient workflows allow clinicians to focus more on patient care rather than paperwork.

How We Support Practices Navigating Value-Based Care

At OmniMD, we understand that small practices need practical tools, not just theory, to succeed in value-based care.

That’s why we work with healthcare organizations to simplify the transition through solutions that support:

MIPS reporting and compliance
Integrated EHR and revenue cycle management
Advanced analytics for population health management
Tools designed to improve patient outcomes and quality performance

By helping practices streamline data management and quality reporting, we enable physicians to focus on what matters most: delivering exceptional patient care.

Conclusion

The healthcare industry’s shift toward value-based care is reshaping how providers deliver and manage patient care. While the transition to value-based reimbursement models can be challenging for independent practices, it also creates an opportunity to improve care quality, strengthen patient relationships, and build long term financial sustainability.

Practices that invest in technology, focus on preventive care, and strengthen care coordination will be better positioned to succeed in this evolving healthcare landscape.

As value-based healthcare continues to expand, small practices that prepare early will have a stronger foundation for delivering high-quality care while remaining financially stable.

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Cybersecurity Essentials for Clinics in 2026

omni — Mon, 06 Apr 2026 05:46:02 +0000

Cybersecurity Essentials for Clinics in 2026

Before we get into the ‘what to do,’ it helps to understand just how big this healthcare cybersecurity problem actually is.

710

Large healthcare data breaches reported in the US in 2025

62M

patient records exposed or stolen in 2025 alone

$12.6M

projected average cost of a single healthcare breach in 2026

That last number is not a typo. A single data breach in healthcare now costs more than many clinics earn in a decade. And that figure accounts for more than just technical recovery, it includes HIPAA fines, legal exposure, lost patients, downtime, and reputational damage that can follow a practice for years.

There’s also a human cost that the numbers can’t fully capture. Cyberattacks on healthcare providers lead to delayed test results, postponed procedures, longer hospital stays, and in some cases, worse patient outcomes. This is why cybersecurity in healthcare isn’t just an IT conversation. It is a patient safety conversation. And it is one that most small clinics are not yet having.

What is Actually Happening Out There

It helps to move past statistics and look at real incidents, because the numbers alone can feel abstract. Two recent cases illustrate exactly how these attacks unfold in practice, and why they affect clinics that never thought they were in the crosshairs.

Change Healthcare (2024): One of the largest healthcare cyber incidents in U.S. history involved a ransomware attack on Change Healthcare, a company that processes insurance claims for hospitals and clinics across the U.S. The result: Up to 100 million individuals may have been affected, claims processing was disrupted nationwide for weeks, and the company reportedly paid about $22 million in ransom. Clinics that had nothing to do with the breach were still affected, because they relied on Change Healthcare as a vendor.

Conduent Business Services (2025): This one is particularly important for small clinics. Conduent, a business associate providing billing and administrative services to healthcare providers, disclosed a breach that potentially affected millions of individuals whose data they held on behalf of clients. The clinics themselves weren’t hacked, their vendor was.

The lesson from both incidents is the same: your exposure is not limited to your own systems. It extends to every third party you share data with.

This matters because it reframes the way clinics need to think about their own risk. It is no longer enough to ask “are our computers secure?” The better question is: “what would happen if the systems we depend on went down tomorrow, and what data do we have that someone else might want?”

Understanding Your Own Risk Before Spending a Dollar

That question leads to what security professionals call risk appetite, which sounds like boardroom language but is actually straightforward. It simply means: how much risk can your practice handle before things get serious?

Before spending a dollar on security tools, every practice should honestly answer four questions:

What data do we actually hold?

Patient records, Social Security numbers, insurance details, prescription history, mental health notes, all of these have different levels of sensitivity and different legal implications if exposed.

How dependent are we on our systems being online?

If your EHR goes down for 48 hours, can you continue seeing patients? If the answer is no, your tolerance for disruption is very low, and your security investment should reflect that.

What would a breach really cost us?

Beyond the technical fix, think about HIPAA fines, the cost of notifying affected patients, legal fees, and the patients who might simply never come back.

Do we have a recovery plan?

Not just backups, but a tested, written process for what happens the morning after an attack.

Risk Level What it looks like What to do

Low

MFA enabled, staff trained, daily encrypted backups, tested incident response plan, HIPAA-compliant tools

Maintain and review quarterly. You’re in good shape.

Medium

Some protections in place but gaps exist — maybe no MFA, or backups aren’t tested, or staff training is irregular

Prioritize the gaps. Get to Low risk within 90 days.

High

No formal security plan, legacy software, shared passwords, no backups, no staff awareness

Act now. A breach at this level can end a practice. Get professional help this week.

The goal is moving your clinic from High to Medium, and from Medium to Low, systematically, affordably, and without disrupting your day-to-day operations. Most clinics that do this exercise honestly discover they have low or medium tolerance for disruption but have invested almost nothing in protection. That gap is where attackers operate.

How Cyberattacks in Healthcare Happen

Understanding the mechanics of an attack makes prevention far less abstract. Most healthcare breaches work through a small number of entry points, and the most common ones are more familiar than you might expect.

Ransomware

Encrypts all your files and demands payment. Healthcare is the #1 ransomware target — 32% of all known ransomware attacks globally hit healthcare in 2025.

Phishing Emails

Fake emails that trick staff into clicking a link or handing over login credentials. One click is often all it takes. Average cost per phishing breach in healthcare: $9.77M.

Supply Chain Attacks

Your billing company, EHR vendor, or cloud storage provider gets hacked — and your patient data goes with them. Over 80% of stolen health records come from third-party vendors.

Credential Theft

Attackers steal a username and password — then simply log in. No hacking needed. No alarms go off. They can sit quietly inside your systems for weeks before striking.

Medical Device Hacks

Connected devices — infusion pumps, monitors, diagnostic equipment — often run outdated software. Hackers use them as a backdoor into your entire network.

Cloud Misconfiguration

A cloud storage bucket set up incorrectly, accessible to anyone who knows where to look. In 2025, one health insurer exposed 4.7 million records this way — for three years undetected.

Of all of these, ransomware deserves a closer look, because it’s the most disruptive and the most misunderstood. A lot of people picture ransomware as a sudden attack. In reality, it’s usually slow and deliberate.

Here’s how a typical ransomware attack on a healthcare clinic unfolds step by step:

Step 1 Phishing email arrives

→

Step 2 Staff clicks the link

→

Step 3 Malware installs silently

→

Step 4 Spreads through network

→

Step 5 Data stolen, files locked

The scariest part?

Steps 3 and 4 can happen over days or weeks, while everything looks perfectly normal. Attackers are patient.

They map your systems, identify what’s valuable, steal copies of your data first, and then flip the switch. That’s why simply “not noticing anything wrong” is not the same as being safe.

Why Small Clinics Are the Target, And Not the Exception

This brings us to the most dangerous myth in healthcare cybersecurity, the belief that only large hospital systems need to worry. That belief has led thousands of independent clinics to leave their doors open.

THE MYTH

“We’re a small clinic. Nobody is going to bother targeting us.”

THE REALITY

Small clinics are often easier targets precisely because of weaker defenses- and hackers know it.

Attackers are not always looking for the biggest prize. They’re looking for the easiest one. Large hospital systems now invest heavily in security teams, 24/7 monitoring, and sophisticated defenses. Small and independent clinics, on the other hand, often rely on shared passwords, basic antivirus software, and the assumption that nobody is watching. That gap is exactly where modern attackers focus their energy.

The data a two-doctor family practice holds is just as valuable on the black market as the same data from a major hospital. Social Security numbers, diagnoses, insurance information, none of that becomes less valuable because it came from a smaller practice. The only difference is how easy it is to steal.

Congress recognized this explicitly when they passed the Healthcare Cybersecurity Act of 2025, which directed federal agencies to provide targeted cybersecurity support specifically to independent and small-group medical practices. Even lawmakers understand that small clinics are in the crosshairs.

Six Cybersecurity Best Practices That Clinics Must Follow

Most cybersecurity guides go wrong here by listing enterprise-grade solutions that cost hundreds of thousands of dollars and require a full security team to maintain. That is not useful for a three-person clinic. The following six practices address the most common ways clinics get breached, and all of them are genuinely achievable regardless of size or budget.

#1 Turn on Multi-Factor Authentication (MFA), everywhere

This is the single most impactful thing you can do. MFA means every login requires a second step, a code texted to your phone, or an app prompt. It stops the vast majority of credential-based attacks cold. Most EHR systems, email platforms, and billing tools already include it. It just needs to be turned on. No exceptions for any account that touches patient data.

#2 Train your staff; regularly, not once

95% of data breaches involve human error. Phishing emails have become extraordinarily convincing, AI can now generate personalized messages that reference your name, your clinic, and your actual vendors. A 30-minute quarterly training session that teaches staff what these look like is worth more than most technical tools. In 2025, just 8% of employees caused 80% of security incidents. Know who your high-risk users are and train them first.

#3 Back up your data daily, and actually test the backups

Encrypted daily backups to a cloud service are your insurance policy against ransomware. If attackers lock your systems, you restore from backup and keep going, no ransom paid. But here’s what most clinics miss: you need to test the restore process regularly. Knowing you have a backup and knowing you can actually use it are two different things. Test yours every quarter.

#4 Update your software, immediately, every time

In 2025, 56% of successfully exploited vulnerabilities required no login, attackers just needed unpatched software. When a software vendor releases a security update, they are publicly announcing that a vulnerability existed. That announcement is a roadmap for attackers. Every day you delay an update is a day that door stays open. Set systems to update automatically wherever possible.

#5 Control who can access what

Your receptionist should not be able to access the same systems as your physician. Your billing coordinator should not have access to clinical notes. And anyone who leaves your practice should lose access on the same day they leave. Access controls limit the damage when any single account is compromised, and they’re built into virtually every modern healthcare platform. This takes minutes to set up and removes an enormous category of risk.

#6 Write an incident response plan, and practice it

An incident response plan is just a written answer to: “What do we do if we get breached tomorrow?” Who calls whom? Who contacts patients? Who notifies HHS? Who talks to the media? Having this written down before it happens means panic doesn’t make the situation worse. Practices with tested response plans recover twice as fast as those without. It doesn’t need to be complicated, even a one-page document is infinitely better than nothing.

What it Costs to Protect a Clinic

The most common reason small clinics give for delaying action is cost. It is worth being direct about what the numbers actually look like, because the comparison is more favorable than most practice managers assume.

Monthly managed cybersecurity services for a small clinic

$200–$500

Covers monitoring, patching, MFA setup, backup management, and basic staff training support

Average cost of a single phishing breach in healthcare

$9.77M

Source: IBM 2024 Cost of a Data Breach Report. Does not include long-term reputational damage.

Managed IT and cybersecurity services, where a dedicated provider handles your security needs remotely, have become the practical answer for small and independent clinics. You get access to expert knowledge, round-the-clock monitoring, and HIPAA-aligned protections without hiring a single full-time IT person. The cost is predictable, usually billed monthly, and scales with your practice size.

Many EHR platforms also include built-in security features, audit logs, automatic logoff, role-based access, that just need to be configured properly. In many cases, you’re already paying for protections you haven’t switched on yet.

And starting in 2026, HIPAA is moving from optional to mandatory on several key controls, including encryption, MFA, and network segmentation. The cost of compliance is going up, but so is the cost of ignoring it. Violations can now reach $50,000 per incident.

So, Where Do You Start?

If you’ve made it this far, you now know more about healthcare cybersecurity challenges and threats in 2026 than most practice managers do. That’s a genuine advantage.

The most important thing is not to let the scale of the problem lead to paralysis. You don’t have to fix everything at once. Start with MFA, turn it on this week for every account that touches patient data. Then schedule a 30-minute staff training session for next month. Then check that your backups are running and that you know how to restore from them.

Those three steps alone put you ahead of the majority of small clinics in the country, and they close the most common entry points that attackers use.

Healthcare cybersecurity is not about becoming impenetrable. It’s about making your clinic a harder target than the one down the street, recovering quickly when something does happen, and ensuring that your patients can always trust you with the most sensitive details of their lives.

That trust is worth protecting. And now you know how.

Not sure where your clinic stands?

Start by auditing the six essentials above. If you’re missing even two or three, it’s worth a conversation with a managed IT provider who specializes in healthcare. Most offer a free initial assessment, and what you learn in 30 minutes could save your practice.

Disclaimer

Statistics sourced from IBM Cost of a Data Breach Report, HHS Office for Civil Rights, Verizon DBIR 2025, and HIPAA Journal. This blog is for informational purposes. Consult a qualified healthcare IT professional for guidance specific to your practice.

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ICD-10 Codes for Obesity and BMI: Billing the GLP-1 Era Correctly

omni — Tue, 31 Mar 2026 08:18:44 +0000

ICD-10 Codes for Obesity and BMI: Billing the GLP-1 Era Correctly

Today, weight management is no longer a side conversation.

A patient may come in for blood pressure, diabetes, sleep issues, joint pain, or general follow-up, and obesity may be part of the bigger picture. At the same time, GLP-1 medications have made weight loss treatment more visible than ever.

That means providers need to document more carefully. And billing teams need to read the chart more carefully.

When the diagnosis is clear, the claim is easier to support. When the note is vague, the whole process becomes harder.

That is why obesity coding and BMI coding matter so much now. They are part of the story the chart tells.

Start with BMI

BMI stands for body mass index.

It is a number based on height and weight. It gives a rough sense of where a person falls on the weight spectrum.

That sounds simple, and it is. But the important thing to remember is this: BMI is a measurement, not a diagnosis.

A BMI number can help show whether a patient may be overweight or in the obesity range, but it does not automatically mean the patient has obesity as a medical condition. The provider has to document that diagnosis.

That distinction matters a lot in coding.

If the chart only says BMI 34, that tells you the measurement. It does not fully tell you the diagnosis. If the provider documents obesity, then the coding team can support that diagnosis properly.

What obesity means in coding

Obesity is a medical condition. It is not just a number on a scale.

It is important because obesity can affect many parts of a patient’s health. It can be linked to diabetes, high blood pressure, heart disease, sleep apnea, and joint problems. In many cases, it is a chronic condition that needs ongoing management.

That is why the diagnosis has to be documented clearly.

The coder cannot guess. The chart has to say it. Once it does, the correct ICD-10 code can be used to reflect the patient’s condition.

The obesity ICD-10 codes you should know

The main adult obesity codes now let providers document the condition more specifically.

Here are the key ones:

E66.811 for class 1 obesity.
E66.812 for class 2 obesity.
E66.813 for class 3 obesity.
E66.9 for unspecified obesity.

These codes matter because they describe the condition more accurately. If a provider documents, the claim should not use a vague code if a more specific one is available.

This is one of the biggest improvements in obesity coding. It helps the chart reflect reality more clearly.

For billers and coders, the rule is simple: use the code that matches the provider’s documentation. If the note gives the class, use the class-specific code. If it does not, unspecified obesity may be used.

Where BMI codes fit in

BMI codes belong to the Z68 category.

These codes capture the patient’s body mass index range. They are often used alongside obesity diagnosis codes because they add useful context.

Think of it this way:

The obesity code tells you the condition.
The BMI code tells you the measurement.

Both pieces can matter on the same claim.

For example, if a patient has class 2 obesity and a BMI of 37.4, the chart becomes much more complete when both are documented correctly. The diagnosis explains what is going on. The BMI supports the measurement behind it.

That combination is often what payers want to see.

Why GLP-1 medications changed the conversation

GLP-1 medications have made weight management much more visible in everyday practice.

These medicines are used in discussions around obesity and weight loss treatment, and that has changed how carefully documentation gets reviewed. Many payers now want to see a clear diagnosis, a matching BMI, and a treatment plan that fits the chart.

This is where a lot of practices feel the pressure.

A provider may prescribe a GLP-1 medication because the patient needs help managing weight. But if the note does not clearly document obesity and BMI, the medical billing process can become much more difficult.

That is why these medications have pushed coding into the spotlight. They have made the link between clinical documentation and reimbursement much more obvious.

What good documentation looks like

Good documentation does not have to be complicated.

In fact, the best notes are usually the clearest ones.

A strong note might say something like:

Patient has class 1 obesity.
BMI today is 31.6.
Discussed diet and exercise.
Reviewed treatment options.
GLP-1 therapy started for weight management.

That kind of note gives the coding team what they need. It also shows the clinical reason for the medication.

A weaker note might simply say:

Weight issues discussed.
BMI elevated.
Follow up as needed.

That does not tell the full story. It leaves too much open. And in medical billing, open-ended notes often lead to problems.

Why payers care so much

Insurance companies care whether the diagnosis matches the treatment.

That is especially true with GLP-1 drugs because they may be expensive, and they are often reviewed carefully before approval. Payers want to know:

Does the patient have a documented obesity diagnosis?
Is the BMI in the chart?
Does the note support the treatment plan?
Is the medication being used appropriately for the condition?

If the answer is yes, the claim is much easier to support. If the answer is unclear, the claim may be delayed or denied.

That is why clear documentation is so important. It helps the payer understand the case without guessing.

Common mistakes that cause billing issues

A lot of obesity coding problems happen for simple reasons.

One common mistake is using a BMI code without a diagnosis.

Another is using a general obesity code when the provider has clearly documented a specific class.

Another is failing to update the diagnosis when the patient’s weight changes over time.

There are also cases where the provider documents overweight when the patient may actually meet obesity criteria. Or the note does not clearly connect the GLP-1 medication to the diagnosis.

These issues can create confusion for billers, coders, and payers.

The good news is that most of these mistakes are preventable. Usually, the fix is just better documentation.

How to think about it in the simplest way

If this is all new to you, here is the easiest way to remember it:

BMI is the number.
Obesity is the diagnosis.
GLP-1 medication is part of the treatment.
ICD-10 codes tell the payer what condition is being treated.
Documentation ties everything together.

When those five pieces line up, the chart makes sense.

And when the chart makes sense, coding becomes easier.

What providers should do

Providers do not need to become coding experts. But they do need to document clearly enough for the claim to stand on its own.

A few simple habits can help:

Write down the BMI when it matters.
State obesity clearly if the patient has it.
Include the obesity class when possible.
Connect the treatment plan to the diagnosis.
Update the chart if the patient’s status changes.

That may sound basic, but basic documentation is often what makes the biggest difference.

For practices looking to build a dedicated weight loss program around these services, this guide on starting a weight loss clinic is a helpful next step.

What billing teams should do

Billing teams play a big role here too.

They should check whether the code matches the note. They should look for specificity. They should make sure the BMI is captured when needed. And they should watch for payer rules around GLP-1 medications and obesity treatment.

If the chart is missing something, it is better to catch it before the claim goes out. That saves time, prevents denials, and makes follow-up easier.

A clean chart is much easier to bill than a confusing one.

Why this is also about patient care

This topic is not only about reimbursement.

It is also about accuracy.

When obesity is coded correctly, the medical record better reflects what the patient is actually dealing with. That helps future visits, care coordination, and long-term follow-up.

It also helps clinicians track progress over time. If a patient loses weight, changes treatment, or moves into a different obesity class, the chart should show that. The record should move with the patient.

That is part of good care.

A practical example

Let’s say a patient comes in for a follow-up visit. The provider documents class 3 obesity, BMI 41.2, and starts a GLP-1 medication.

That note gives the billing team a clear path. The diagnosis is specific. The BMI is documented. The treatment is tied to the condition.

Now compare that to a note that only says, “discussed weight loss.”

That second note is much harder to use. It does not explain the diagnosis or the reason behind the treatment. It leaves too much unanswered.

That is the difference good documentation makes.

The bigger takeaway

The GLP-1 era has changed obesity care. It has also changed obesity coding.

BMI still matters. Obesity diagnosis still matters. The ICD-10 code still has to match the chart.

But now the stakes are higher because weight management is more closely tied to treatment decisions, payer review, and ongoing care.

If your practice wants cleaner claims and clearer records, the goal must be to:

document the diagnosis clearly,
include BMI when appropriate,
use the right obesity code,
and make sure the chart supports the treatment.

That is the cleanest way to approach obesity coding today.

Final thoughts

For someone new to this topic, the key takeaway is to remember that obesity coding is really about clarity.

The chart has to show what the patient has, what the measurement is, and what treatment is being used. When those pieces fit together, billing gets easier and care gets better.

In the GLP-1 era, that is more important than ever.

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ICD-10-CM 2026 Updates: What Every Medical Practice Needs to Know

omni — Mon, 30 Mar 2026 11:31:10 +0000

ICD-10-CM 2026 Updates: What Every Medical Practice Needs to Know

Monday mornings at a busy clinic usually begin the same way. The front desk checks patients in, nurses prepare charts, and the billing teams reviews claims submitted the previous week. Everything moves smoothly until a small coding issue brings the workflow to a halt.

A denied claim, an outdated diagnosis code or a missing documentation can quickly disrupt the revenue cycle. This is why annual coding changes matter more than many practices realize.

The ICD-10-CM 2026 updatestaking effect on October 1, 2025, marking the start of the 2026 federal fiscal year for medical coding, introduce hundreds of changes that healthcare providers, coders, and billing teams need to prepare for. Understanding these updates early can help practices avoid claim denials, improve documentation accuracy, and maintain a smooth billing workflow.

Why ICD-10 Updates Matter for Clinics

Each year, healthcare regulators update diagnosis codes to reflect changes in medicine, disease classification, and clinical documentation practices. These revisions help ensure that patient records accurately represent the care being delivered.

For medical practices, however, coding updates also influence several operational areas:

Claim acceptance rates
Revenue cycle efficiency
Clinical documentation accuracy
Reporting and compliance requirements

Even small coding changes can have a noticeable impact on a clinic’s billing performance if staff members continue using outdated codes.

ICD-10-CM 2026 Updates at a Glance

The upcoming ICD-10 coding updates for 2026 introduce new codes, revisions, and guideline clarifications designed to improve clinical specificity and reporting accuracy.

Category	Number of Codes	Key Highlights	Clinical Impact
New Codes	487	Expanded reporting for chronic ulcers, injuries, neoplasms, and social determinants	Improves diagnostic precision and patient data reporting
Revised Codes	38	Updated descriptions and coding guidance for conditions such as HIV and inflammatory breast cancer	Aligns documentation with modern clinical standards
Deleted Codes	28	Outdated or replaced codes removed	Prevents inaccurate claims and billing errors
Guideline Clarifications	Multiple	Updated sequencing rules and Excludes notes	Reduces coding confusion and improves consistency
Specificity Enhancements	N/A	Greater detail for laterality, severity, and episodes of care	Supports improved reimbursement accuracy

These changes emphasize one major trend in healthcare documentation: greater diagnostic specificity.

What These Updates Mean for Your Practice

For many clinics, coding updates are not just administrative changes — they directly affect daily workflows.

1. Documentation Will Need More Detail

Physicians may need to document additional information in patient charts, including:

Laterality (left, right, bilateral)
Severity or stage of conditions
Episode of care
Contributing health or environmental factors

Without this level of detail, coders may struggle to select the most accurate diagnosis code.

2. Coding and Billing Teams Must Update Workflows

Using outdated codes after October 2025 can lead to several problems:

Claim rejections from payers
Delayed reimbursements
Additional administrative work for corrections

Updating internal coding references and training staff ahead of the transition helps minimize these disruptions.

3. Electronic Systems Must Be Updated

Electronic health record systems and billing platforms typically integrate the latest ICD-10 codes automatically. However, practices should still confirm that their systems are updated before the new codes become active.

Many organizations schedule internal coding audits during this period to ensure their workflows remain compliant.

Examples of Diagnosis Codes Practices May See

Some of the updates in the ICD-10-CM 2026 code set introduce additional specificity for common conditions.

Code	Description	Typical Clinical Use	Clinical Impact
L97.123	Non-pressure chronic ulcer of right lower leg, stage 3	Wound care documentation and severity tracking	Improves diagnostic precision and patient data reporting
C50.912	Malignant neoplasm of unspecified site of left female breast	Oncology diagnosis documentation	Aligns documentation with modern clinical standards
Z59.89	Other problems related to housing and economic circumstances	Reporting social determinants affecting patient care	Prevents inaccurate claims and billing errors
S82.841A	Fracture of shaft of right tibia, initial encounter	Orthopedic injury documentation	Reduces coding confusion and improves consistency
Specificity Enhancements	N/A	Greater detail for laterality, severity, and episodes of care	Supports improved reimbursement accuracy

These examples highlight how modern coding standards require more precise documentation than in previous years.

Specialties That May See Larger Changes

While every clinic must adopt the 2026 medical coding updates, certain specialties may notice a greater impact.

Primary Care
Primary care providers often document chronic conditions, preventive visits, and social determinants of health. Many of the new codes expand reporting options for these areas.

Orthopedics
Fracture and injury classifications continue to become more detailed, requiring accurate documentation of injury location and treatment stage.

Oncology
Updated neoplasm classifications support improved cancer reporting and treatment tracking.

Cardiology
Cardiovascular complications and sequelae codes continue to expand as clinical treatment pathways evolve.

Preparing Your Practice for ICD-10-CM 2026

A proactive approach can make the transition significantly easier.

Preparation Step	Benefit for Practices
Review new and revised codes	Prevents use of outdated codes
Train coders and billing staff	Improves claim accuracy
Educate physicians on documentation needs	Ensures proper coding specificity
Update EHR and billing software	Supports compliant claims submission
Conduct internal coding audits	Identifies potential workflow gaps

Practices that begin preparing several months before the effective date typically experience fewer disruptions.

Key Takeaways

The ICD-10-CM 2026 updates may appear technical at first glance, but their real impact is operational. Coding accuracy influences nearly every part of a healthcare organization, from documentation to reimbursement.

By reviewing new codes, updating workflows, and training staff early, medical practices can transition smoothly and avoid unnecessary billing complications.In a busy clinical environment where efficiency matters, staying ahead of coding changes is one of the simplest ways to protect both financial performance and documentation quality.

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MIPS 2026 Explained: Scoring, Measures, and How to Avoid Penalties

omni — Fri, 27 Mar 2026 05:07:33 +0000

MIPS 2026 Explained: Scoring, Measures, and How to Avoid Penalties

Healthcare reimbursement in the United States has been changing steadily from volume-based payments to value-based care. Instead of simply paying providers for the number of services they have delivered, Medicare increasingly evaluates the quality, efficiency, and outcomes of those services.

One of the key programs supporting this transition is the Merit-based Incentive Payment System (MIPS). As part of Medicare’s value-based payment framework, MIPS evaluates the performance of clinicians using several quality and efficiency measures that directly affect reimbursement.

For healthcare providers and practice administrators, understanding how MIPS works in 2026 is essential. Scoring thresholds, reporting requirements, and performance categories all play a role in determining whether a practice receives a payment incentive or a penalty.

This guide explains MIPS 2026 scoring, the major performance measures, and practical steps healthcare organizations can take to avoid penalties.

What Is MIPS?

The Merit-based Incentive Payment System (MIPS) is a performance-based reimbursement program created under the Medicare Access and CHIP Reauthorization Act (MACRA). The program is administered by the Centers for Medicare & Medicaid Services (CMS) and applies to clinicians who bill Medicare Part B.

MIPS evaluates clinicians based on several performance metrics, including care quality, cost efficiency, use of health information technology, and participation in practice improvement activities.

Each year, clinicians receive a Composite Performance Score (CPS) based on these metrics. This score determines whether Medicare payments will increase, remain neutral, or decrease in future payment years.

Because payment adjustments can reach up to a 9 percent penalty, MIPS reporting and performance have become a critical part of revenue planning for many healthcare organizations.

Who Needs to Participate in MIPS?

Not all clinicians are required to participate in MIPS. Participation depends on whether a provider exceeds the Low-Volume Threshold (LVT) established by CMS.

Clinicians typically must participate if they exceed all of the following thresholds during the determination period:

More than $90,000 in Medicare Part B allowed charges
More than 200 Medicare patients
More than 200 covered professional services

Eligible clinicians commonly include:

Physicians
Nurse practitioners
Physician assistants
Clinical nurse specialists
Certified registered nurse anesthetists

Providers who fall below the threshold may be exempt but can sometimes opt in voluntarily if they wish to participate in the program.

How MIPS Scoring Works in 2026

MIPS uses a Composite Performance Score (CPS) that ranges from 0 to 100 points. This score is calculated using several performance categories, each with a specific weight.

For the 2026 performance year, the performance threshold remains 75 points. Providers who score above this threshold may receive a positive payment adjustment, while those who score below it risk financial penalties.

The impact of MIPS scoring usually occurs two years after the performance year. For example, performance in 2026 may affect Medicare payments in 2028.

The payment adjustment structure generally follows this model:

Composite Score	Payment Impact
Above threshold	Positive payment adjustment
Equal to threshold	Neutral payment
Below threshold	Negative payment adjustment

Because the program is budget-neutral, penalties from lower-performing providers help fund incentives for higher performers.

The Four MIPS Performance Categories

MIPS scoring is based on four major performance categories. Each category contributes a percentage toward the final Composite Performance Score.

Category	Weight
Quality	30%
Cost	30%
Promoting Interoperability	25%
Improvement Activities	15%

Understanding how each and every category works is truly essential for improving overall performance.

Quality (30%)

The Quality category evaluates how effectively clinicians deliver care and manage patient outcomes.

Providers typically report six quality measures, including at least one outcome measure when available. These measures focus on areas such as preventive care, chronic disease management, patient safety, and clinical effectiveness.

Examples of quality measures may include:

Preventive screenings
Blood pressure control
Medication reconciliation
Chronic condition management

CMS regularly updates the list of available measures. For 2026, several measures have been added, modified, or removed to improve accuracy and clinical relevance.

Cost (30%)

The Cost category evaluates how efficiently healthcare services are delivered. Unlike other categories, providers do not need to submit data for cost measures. CMS calculates these scores automatically using claims data.

Common cost measures include:

Medicare Spending per Beneficiary (MSPB)
Total Per Capita Cost (TPCC)
Episode-based cost measures for specific conditions or procedures

This category encourages clinicians to deliver high quality care while avoiding unnecessary spending or duplicated services.

Promoting Interoperability (25%)

The Promoting Interoperability category focuses on the use of certified electronic health record (EHR) technology to improve care coordination and patient engagement.

This category evaluates whether clinicians effectively use digital tools to share and access health information.

Key objectives often include:

Electronic prescribing
Health information exchange
Patient access to electronic health records
Reporting to public health agencies

Healthcare organizations that integrate EHR workflows effectively often find it easier to meet these requirements.

Improvement Activities (15%)

The Improvement Activities category measures how practices enhance clinical processes and patient care.

Clinicians typically must complete activities for a minimum of 90 days during the performance year.

Common activities may involve:

Expanding care coordination programs
Improving patient safety initiatives
Implementing population health management strategies
Strengthening patient engagement efforts

These activities help practices demonstrate ongoing efforts to improve quality and operational efficiency.

Key MIPS Updates for 2026

Several changes and ongoing developments continue to shape the MIPS program in 2026.

Continued transition toward MIPS Value Pathways (MVPs)

CMS is gradually shifting toward MIPS Value Pathways (MVPs). These pathways organize reporting around specialty specific measures, making the reporting process more focused and clinically relevant.

Updates to quality measures

CMS regularly reviews quality measures to ensure they reflect current clinical standards. Some measures may be retired, while new measures may be introduced.

Expanded cost measurement methods

Cost reporting continues to evolve with updated episode based measures and improved feedback reporting for clinicians.

How Technology Can Simplify MIPS Reporting

Managing MIPS reporting can be complicated for healthcare organizations. Keeping track of performance, following reporting rules, and submitting accurate data often requires teamwork between clinical and administrative staff.

Many practices use healthcare technology to make this easier. Integrated systems can automate documentation, track quality measures, and help with accurate reporting throughout the year.

OmniMD’s MIPS and MACRA management tools are built to support providers during the entire reporting process. By combining clinical documentation, performance tracking, and reporting in one platform, practices can see their progress and fix gaps before deadlines.

With the right technology, healthcare organizations can reduce administrative work while improving their ability to meet MIPS requirements and avoid penalties

Conclusion

As value-based care continues to shape the healthcare landscape, programs like MIPS play an increasingly important role in determining Medicare reimbursement. Understanding how MIPS scoring works, selecting the right measures, and monitoring performance throughout the year can help providers avoid penalties and improve financial outcomes.

With the support of modern healthcare technology like OmniMD, practices can navigate MIPS requirements more confidently while continuing to focus on delivering high quality patient care.

Frequently Asked Questions (FAQs)

Q: Why is MIPS important for healthcare providers?

MIPS plays an important role in Medicare’s shift toward value-based care. The program evaluates clinician performance based on quality, efficiency, and patient care outcomes. Strong performance can lead to higher Medicare reimbursements, while lower scores may result in financial penalties.

Q: How often do MIPS payment adjustments occur?

MIPS payment adjustments do not occur immediately after the performance year. Typically, there is a two-year gap between reporting and payment adjustments. For example, performance during one reporting year may impact Medicare reimbursement payments two years later.

Q: Do providers need to submit data for the Cost category?

No, clinicians do not need to directly submit data for the Cost category. The score is automatically calculated by Medicare using claims data. This evaluation analyzes the overall cost of care provided to Medicare beneficiaries compared to national benchmarks.

Q: What role does EHR technology play in MIPS reporting?

Electronic Health Record (EHR) systems play a significant role in MIPS reporting, especially within the Promoting Interoperability category. Certified EHR technology helps providers track performance measures, exchange health information, and support accurate reporting to Medicare.

Q: Can small practices successfully participate in MIPS?

Yes, small practices can participate successfully in MIPS. Medicare provides certain flexibilities and support programs designed to help smaller healthcare organizations meet reporting requirements and improve performance scores.

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ICD-10 Codes for Diabetes: A Complete Documentation & Billing Guide

omni — Thu, 26 Mar 2026 13:18:38 +0000

ICD-10 Codes for Diabetes: A Complete Documentation & Billing Guide

WHO THIS GUIDE IS FOR

Whether you are coding your very first claim or have been billing for decades, this guide works for you. Every term is explained the first time it appears. Every rule is followed by a clear example.

Newer coders can read it from start to finish. Experienced coders can jump straight to the section they need. Let’s get started now.

Understanding ICD-10: The Basics Everyone Needs

Before we touch a single diabetes code, we need to make sure we are all speaking the same language. Whether you are brand new to medical coding or you have been doing this for years, this foundation matters.

Experienced coders sometimes get claims denied not because they do not know the codes, but because a basic rule got skipped somewhere along the way. So let’s walk through this together.

ICD-10 stands for International Classification of Diseases, 10th Revision. Think of it as a universal dictionary that everyone in healthcare agrees to use. Instead of a doctor writing “the patient has diabetes with kidney damage” and every insurance company interpreting that differently, we all agree to use a short code that means the exact same thing to everyone, everywhere.

The version used in the United States is called ICD-10-CM. The CM stands for Clinical Modification, meaning it has been adapted specifically for how American providers document diagnoses.

Now here is something worth understanding early. A code is only as good as the documentation behind it. You cannot make up a code because the patient looks like they have a certain condition.

You cannot pull a code from a lab result. A physician or qualified provider must explicitly write the diagnosis in the chart. That one rule prevents more billing problems than any other.

How a code is actually built

Every ICD-10-CM code has up to seven characters, and each one adds a layer of meaning. Let’s use a real example to make this click.

Take the code E11.3511. Here is what each part says:

E11 = Type 2 diabetes mellitus
.35 = with proliferative diabetic retinopathy (a serious eye complication)
1 = with macular edema (swelling in the center of the retina)
1 = right eye

So that one code tells the entire story like this is a Type 2 diabetic patient who has the most severe form of diabetic retinopathy, with swelling in the macula, specifically in the right eye. Five separate clinical facts in seven characters. That is the power of the system, and it is also why using a vague code when a specific one exists is such a big problem. Payers notice, auditors notice, and risk adjustment models notice.

The rule you need to remember here is that always use the most specific code the documentation supports. If a more detailed code exists and the physician documented the details, you must use it.

What Are The Five Types of Diabetes in ICD-10

Now that you understand how the code system works, let’s talk about diabetes specifically. This is where a lot of coders, even experienced ones, make their first mistake: they treat all diabetes the same. They default to one code for every diabetic patient. That is a problem, because ICD-10 recognizes that diabetes is not one disease. It is a group of conditions that all involve blood sugar problems, but for very different reasons. And the reason matters for the code.

There are five main diabetes categories in ICD-10-CM:

E08 is used when another disease caused the diabetes. For example, chronic pancreatitis can destroy the insulin-producing cells in the pancreas over time and lead to diabetes. Hemochromatosis, Cushing syndrome, and cystic fibrosis can do the same. If the physician documents that one of these conditions caused the diabetes, E08 is your category.

E09 is used when a drug or chemical caused the diabetes. The most common culprit is steroids like prednisone, which are widely prescribed for inflammation and autoimmune conditions. Certain antipsychotic medications, some diuretics, and transplant drugs can also trigger diabetes. When the physician explicitly says the drug caused the diabetes, E09 applies.

E10 is Type 1 diabetes. This is an autoimmune disease. The patient’s own immune system attacks and destroys the beta cells in the pancreas that produce insulin. Without those cells, the body cannot make insulin at all. These patients depend on insulin injections or a pump to stay alive.

E11 is Type 2 diabetes. This is by far the most common form, representing roughly 90 to 95 percent of all diabetes cases. In Type 2, the body either does not make enough insulin or does not respond to it properly. It is strongly associated with obesity, physical inactivity, and family history.

E13 is the catch-all for diabetes that does not fit anywhere else. This includes diabetes that developed after surgical removal of the pancreas, MODY (Maturity Onset Diabetes of the Young, which is a genetic form), neonatal diabetes, and post-procedural diabetes.

One quick note: there is no E12. It existed in an older version of the system and was deleted. If you see it on an old charge sheet or superbill, it needs to be updated.

How to Pick the right category every time

The easiest way to choose the right category is to know what caused this patient’s diabetes? To do so, work through this logic:

Did another disease cause it?

Use E08, and always code that underlying disease first before E08.

Did a drug cause it?

Use E09, and always code the drug’s adverse effect first before E09.

Is the patient explicitly documented as Type 1?

Use E10. If none of the above, default to E11.

That sequencing rule for E08 and E09 is not optional. ICD-10-CM Official Guidelines require it. The cause always comes before the diabetes code.

What about gestational diabetes?

Gestational diabetes is diabetes that develops during pregnancy, and it is handled completely separately. It does not use E codes at all. It lives in the obstetrics chapter under O24.4, and the specific code depends on how the diabetes is being managed:

O24.410 = controlled by diet
O24.414 = controlled by insulin
O24.415 = controlled by oral medications

One important rule about insulin and Type 1

There is a code called Z79.4 that means “long-term current use of insulin.” You do not add it with E10 codes. Since Type 1 patients are always on insulin by definition, the code would be redundant. Z79.4 is only added for Type 2 patients (and E08, E09, E13 patients) who use insulin. Keep that distinction clear and you will avoid a common coding error.

How to CodeI CD-10 diabetes type 2 (E 11)

Type 2 is where the majority of your diabetes coding work will happen. Because it is so common, it is also where the most errors accumulate. The biggest single error in all of diabetes coding is using E11.9 ICD-10 code for every Type 2 patient at every visit, regardless of what the chart actually says. ICD-10 E11.9 code means no complications, and many diabetic patients absolutely have complications. Coding them as complication-free when they are not is inaccurate, underpays the practice, and can trigger audits.

Let’s go through the most important E11 codes and what each one requires:

E11.9 = Type 2 without complications. Appropriate only when the full chart review confirms no complications are documented.
E11.42 = Type 2 with peripheral polyneuropathy. This is the most common nerve complication. The physician should document “diabetic peripheral neuropathy” or “polyneuropathy due to diabetes.”
E11.43 = Type 2 with autonomic neuropathy. This affects automatic body functions like digestion, heart rate, and bladder control.
E11.12 = Type 2 with kidney disease, stage 3. Requires both physician documentation of diabetic nephropathy AND a separate CKD stage code (N18.3 in this case).
E11.311 = Type 2 with retinopathy and macular edema. Physician must specify the type of retinopathy and which eye.
E11.51 = Type 2 with circulatory problems in the extremities, no gangrene
E11.52 = Type 2 with circulatory problems in the extremities WITH gangrene. Never use this without explicit physician documentation of gangrene.
E11.621 = Type 2 with diabetic foot ulcer. Must be paired with an L97.x code for the ulcer’s location and severity.
E11.649 = Type 2 with low blood sugar, patient stayed conscious
E11.641 = Type 2 with low blood sugar, patient lost consciousness
E11.65 = Type 2 with high blood sugar episode documented this visit

Medication add-on codes for Type 2

Unlike Type 1, Type 2 patients may control their blood sugar with insulin, oral medications, or diet alone. ICD-10 wants to capture that, so there are secondary codes to add:

When the patient uses insulin, always add Z79.4. When the patient uses oral diabetes medications like metformin or glipizide, always add Z79.84. When the patient uses both, add both Z79.4 and Z79.84. When the patient manages diabetes with diet alone, no Z code is needed.

What About E08, E09, and E13 Codes?

These three categories are used less often than E11, but skipping them when they apply is a real compliance risk. Let’s walk through each one so you know exactly when and how to use them.

E08 : When another disease caused the diabetes

The key word with E08 is causation. The physician must not just document that the patient has both pancreatitis and diabetes. The physician must state that the pancreatitis caused the diabetes. One common scenario is a patient with years of chronic pancreatitis whose pancreatic tissue has been so damaged that the insulin-producing cells no longer function. That is E08 territory.

Other conditions that can cause E08 diabetes include hemochromatosis, which is iron overload disease, Cushing syndrome, and malignant tumors of the pancreas.

Sequencing rule, repeated because it matters: the underlying condition always comes first.

Example: a patient whose chronic pancreatitis caused diabetes with nerve damage would be coded as:

K86.1 (chronic pancreatitis)
E08.40 (diabetes due to underlying condition with neuropathy)

E09: When a drug caused the diabetes

E09 follows the same logic but for medications. Steroids are the number one cause. A patient on long-term prednisone for rheumatoid arthritis who develops diabetes as a direct result of that treatment is an E09 patient.

The drug is always coded first using what is called an adverse effect T-code, which comes from the Table of Drugs and Chemicals in the ICD-10 manual.

Example: steroid-induced diabetes from long-term prednisone, no complications yet, patient started on insulin:

T38.0X5A (adverse effect of glucocorticoids, initial encounter)
E09.9 (drug-induced diabetes, no complications)
Z79.4 (long-term insulin use)

E13: Everything else

E13 is used for diabetes that does not fit E08 through E11. The most common situations are diabetes following surgical removal of the pancreas, MODY, neonatal diabetes, and certain secondary forms with an unspecified cause that do not match E08 or E09. The complication structure inside E13 works exactly the same as E11, so E13.42 means the same type of complication as E11.42, just under a different root cause.

Coding Complications: The Part That Changes Everything

Here is where accurate coding either happens or breaks down. Complications are the clinical details that tell the real story of how sick a patient is. They are also what most payers, auditors, and risk adjustment models are looking at most closely.

The rule is simple: code every confirmed complication that is documented in the record for that encounter. There is no limit on how many complication codes you can report. If three complications are documented, code all three.

Kidney complications

Diabetic kidney disease is one of the most common long-term complications of diabetes. The complication codes fall under the .1x extension and require you to know the CKD stage:

.11 = CKD stages 1 or 2 (early damage, function still mostly intact)
.12 = CKD stage 3 (moderate damage)
.13 = CKD stage 4 (severe damage)
.14 = CKD stage 5 or end-stage renal disease (kidney failure, patient may be on dialysis)
.10 = kidney involvement, stage not specified

Whenever you use any of these, you must also add a second code from the N18 category for the CKD stage. E11.13 and N18.4 belong together. One code without the other is incomplete.

Eye complications

Diabetic retinopathy is damage to the blood vessels in the retina. Eye codes are the most detailed in the entire diabetes section, and they require three things from the physician:

The type and severity of retinopathy,
Whether macular edema is present, and
Which eye or eyes are affected.

The severity levels move from mild non-proliferative (early, background changes) to moderate non-proliferative, to severe non-proliferative, and finally to proliferative retinopathy, which is the most advanced form where new fragile blood vessels grow on the retina and can rupture and bleed.

The final digit identifies the eye: 1 for right, 2 for left, 3 for both eyes, 9 when the eye is not specified.

If the physician documents which eye but you code it as unspecified, that is undercoding. If the physician says moderate and you code mild, that is inaccurate. Read the ophthalmology or optometry note carefully.

Nerve complications

Diabetic neuropathy means the high blood sugar has damaged the nerves over time. There are four specific types worth knowing:

.40 = neuropathy, type not specified. Use this only when the chart does not indicate which type.
.41 = mononeuropathy, meaning damage to one specific nerve
.42 = polyneuropathy, meaning damage to many peripheral nerves. This is what most charts will call peripheral neuropathy, and it is the most common type.
.43 = autonomic neuropathy, which affects the nerves that control automatic functions. Patients may have gastroparesis, heart rate irregularity, or bladder dysfunction as a result.
.44 = amyotrophy, a rare and severe form involving muscle weakness and wasting

Circulation complications

E11.51 = peripheral angiopathy without gangrene
E11.52 = peripheral angiopathy with gangrene

The word gangrene must appear in the physician’s documentation. Do not use .52 based on a wound that appears necrotic or non-healing without that specific word. If gangrene is present, add a companion code from the L category as well.

Skin and other complications

E11.620 = diabetic dermatitis (skin changes caused by diabetes)
E11.621 = diabetic foot ulcer. This must be paired with an L97.x code that specifies the location and severity of the ulcer.
E11.622 = other skin ulcer. Pair with L98.x.
E11.630 = diabetic periodontal disease
E11.610 = Charcot joint, which is severe joint damage that occurs when nerve loss allows repeated unnoticed trauma to accumulate

Blood sugar episodes

E11.65 = hyperglycemia. Use this when the physician documents a high blood sugar episode during this specific encounter.
E11.649 = hypoglycemia without loss of consciousness
E11.641 = hypoglycemia with loss of consciousness

Coding multiple complications at the same time

A single patient often has several complications at once, and all of them should be coded. Here is what a fully coded complex patient looks like:

Type 2 diabetic on insulin and metformin, with peripheral polyneuropathy, stage 3 diabetic kidney disease, and moderate non-proliferative retinopathy in both eyes:

E11.42 (polyneuropathy)
E11.12 (CKD stage 3)
N18.3 (CKD stage 3, required companion code)
E11.3313 (moderate non-proliferative retinopathy, bilateral, no macular edema)
Z79.4 (long-term insulin use)
Z79.84 (long-term oral hypoglycemic use)

Why Your ICD- 10 Codes for Diabetes Directly Affect How Much Your Practice Gets Paid

Everything we have covered so far affects one thing beyond clinical accuracy, and that is money. Not because coding should ever be done just to maximize revenue, but because accurate coding of how sick your patients actually are is what drives appropriate payment. This is the world of HCC risk adjustment, and it is something every coder and practice manager needs to understand.

HCC stands for Hierarchical Condition Category. It is a scoring model used by Medicare Advantage plans and many commercial payers to calculate how much they pay a practice to manage its patient population. The logic is straightforward: sicker patients require more care, more monitoring, more medications, and more resources. Payers pay more for practices that are managing genuinely sick patients. But the only way payers know how sick your patients are is by reading your diagnosis codes.

There are three HCC tiers for diabetes:

HCC 17 covers diabetes with acute complications. This carries the highest risk weight.
HCC 18 covers diabetes with chronic complications, meaning things like neuropathy, nephropathy, retinopathy, and circulatory problems. This carries a meaningful risk weight.
HCC 19 covers diabetes without any complications, which is just a code like E11.9. This carries the lowest risk weight.

When a patient who genuinely has neuropathy and kidney disease is coded every year as E11.9, they fall into HCC 19. The practice is being paid as if that patient is far healthier than they actually are. Now multiply that by 50 patients, or 150, and you start to see the scale of the problem.

There is another important rule here: HCC models do not carry codes forward from year to year. Every diagnosis must appear on at least one claim in each calendar year. If you captured diabetic neuropathy in January but the patient did not return until the following year and you did not code it again, it disappears from the risk model for the gap year.

This is why annual wellness visits, chronic care management encounters, and any routine follow-up must capture all active chronic conditions, not just the presenting complaint.

Preparing for Accurate ICD-10 Codes For Diabetes

Understanding which codes exist is only half the job. The other half is knowing what the physician must document before you are allowed to use them. This section closes that gap.

The foundational rule is if it is not written in the chart by a qualified provider, you cannot code it. A high HbA1c in the lab results does not let you code diabetes. Metformin on the medication list does not let you code diabetes. A wound that looks like a diabetic ulcer does not let you code a diabetic ulcer. The physician must write the diagnosis.

What must be documented for each category

For any diabetes code, the physician must state the type of diabetes. “Diabetes” alone, without a type, is not ideal. In that situation, ICD-10 defaults to Type 2 (E11), but a specific statement is always better.
For any complication code, the physician must connect the complication to the diabetes. “The patient has CKD and Type 2 diabetes” is not enough. The chart needs to say “diabetic nephropathy” or “CKD secondary to Type 2 diabetes.” The link must be explicit.
For E08, the physician must name the underlying condition and state that it caused the diabetes.
For E09, the physician must name the specific drug and state that it caused the diabetes.
For eye codes, the physician or eye care provider must document which eye or eyes are involved.
For kidney codes, the physician must document the CKD stage. The stage cannot be inferred from lab values alone.
For gangrene codes, the physician must use the word gangrene. A necrotic-looking wound without that explicit word does not qualify.

When to send a physician query

A physician query is a formal written or verbal request asking a provider to clarify something in the documentation. You should query when:

The chart shows a high HbA1c or a diabetes medication but no explicit diabetes diagnosis is written anywhere. The physician likely intended to document it but did not.

A specialist’s note mentions a complication but the treating physician’s note does not connect it to the diabetes. For example, a nephrologist’s note says “diabetic nephropathy” but the primary care note does not mention it.

The type of diabetes is unclear. A young, thin patient on insulin with no family history of Type 2 diabetes may well be Type 1, but the chart just says “diabetes mellitus.”

A drug known to cause diabetes appears on the medication list but the physician never drew a connection between it and the patient’s diabetes diagnosis.

CKD is documented but the stage is missing.

Queries must be objective. You present the clinical facts and ask for clarification. You do not suggest a specific answer. Your organization’s compliance policy should guide the exact format.

What You Must Avoid While Coding

Even coders who know all the rules make errors when workflows get rushed or habits get ingrained. Here are the most common ones along with exactly how to fix each one.

Defaulting to E11.9 for every diabetic patient

This is the single most common diabetes coding error. The coder opens the chart, sees “Type 2 diabetes,” types E11.9, and moves on without checking whether complications are documented anywhere. The fix is to make a full chart review, including specialist notes, the problem list, and any attached consult reports, a non-negotiable step before assigning any diabetes code.

Forgetting Z79.4 for Type 2 patients on insulin

The code is easy to overlook because it is a secondary code, not the primary diabetes code. Build a habit: whenever you code any E11.x for a patient, immediately check the medication list. If insulin is there, Z79.4 goes on the claim.

Wrong sequencing for E08 and E09

This one shows up on audits regularly. The diabetes code gets listed first, but the underlying disease or the drug should always come before it. Repeat the rule until it becomes automatic: cause first, diabetes second, complication third.

Coding a complication without the physician’s causal link

The patient has both CKD and diabetes, so the coder uses E11.12. But the physician note never says “diabetic nephropathy.” The chart just says both conditions exist. That is not enough. Always verify the physician explicitly connected the complication to the diabetes. If not, query before coding.

Missing the required companion codes

Certain diabetes codes are incomplete without a second code. E11.12 needs N18.x. E11.621 needs L97.x. These pairs exist because the diabetes code tells you what caused the problem, but the companion code tells you how severe it is. One without the other is a claim waiting to be denied or queried.

Coding resolved complications as if they are still active

An old diabetic ulcer that healed two years ago can linger on a problem list indefinitely. Coding it as active when it has resolved is inaccurate. Use Z86.39, which is the personal history of complications of diabetes, for conditions that no longer exist.

Using unspecified codes when specific ones are available

E11.40 means the neuropathy type is not specified. But if the chart clearly documents peripheral polyneuropathy, the right code is E11.42. Always read the full description before choosing between a general and a specific code. Auditors treat the consistent use of unspecified codes as a sign of inadequate documentation review.

Finally, Let’s Apply Medical Codes in Clinical Practices

The best way to make all of this stick is to see it applied to actual clinical situations. Let’s walk through four common scenarios together.

Scenario A: The routine Type 2 visit

A 58-year-old woman comes in for diabetes management. She has Type 2 diabetes and takes metformin twice daily. Her HbA1c is 7.2%. No complications are documented anywhere in the chart.

Codes:

E11.9 (Type 2 without complications, confirmed by chart review)
Z79.84 (long-term use of oral hypoglycemic agent, which is what metformin is)

She is not on insulin, so Z79.4 does not apply.

Scenario B: The complex Type 2 patient

A 67-year-old man has Type 2 diabetes managed with nightly insulin and metformin. Today’s note documents peripheral polyneuropathy in both feet, background non-proliferative retinopathy in the left eye without macular edema, and CKD stage 3 due to diabetic nephropathy.

Codes:

E11.42 (polyneuropathy)
E11.3212 (non-proliferative retinopathy, left eye, no macular edema)
E11.12 (diabetic CKD stage 3)
N18.3 (CKD stage 3, required companion code)
Z79.4 (long-term insulin use)
Z79.84 (long-term use of oral hypoglycemic agent)

Scenario C: Steroid-induced diabetes

A 45-year-old woman has been on long-term prednisone for rheumatoid arthritis. Her physician documents new-onset diabetes due to long-term steroid use. No complications yet. She is started on insulin.

Codes:

T38.0X5A (adverse effect of glucocorticoids, initial encounter — goes first because the drug caused the diabetes)
E09.9 (drug-induced diabetes, no complications)
Z79.4 (long-term insulin use)

The temptation here is to use E11 because she is a new diabetic and many new diabetics get coded as Type 2 by default. But the physician explicitly stated the steroid caused the diabetes, which means E09 is correct.

Scenario D: Diabetes caused by chronic pancreatitis

A patient has had chronic pancreatitis for years from alcohol use. The physician documents “diabetes mellitus due to chronic pancreatitis.” No complications are present.

Codes:

K86.1 (chronic pancreatitis, coded first because it is the underlying cause)
E08.9 (diabetes due to underlying condition, no complications)

Reference Tables

These tables bring together everything in this guide in a format you can check quickly while actively coding.

Master category guide

Code	Type	Key Rule
E08	Caused by another disease	Underlying condition coded first
E09	Caused by a drug	Adverse effect T-code coded first
E10	Type 1	No Z79.4 needed; insulin is implied
E11	Type 2 (default)	Add Z79.4 for insulin; Z79.84 for oral agents
E13	Other specified	Post-surgical, MODY, neonatal
O24.4	Gestational	Obstetrics chapter only; not E codes

Complication extension guide

Extension	Complication	Always Add
.1x	Kidney / nephropathy	N18.x for CKD stage
.2x	Peripheral vascular	Gangrene code if gangrene is present
.3x	Eye / retinopathy	Laterality required (1=right, 2=left, 3=both)
.4x	Nerve / neuropathy	Nothing extra required
.5x	Circulatory	Nothing extra required
.621	Foot ulcer	L97.x for ulcer location and severity
.622	Other skin ulcer	L98.x for ulcer detail
.64x	Hypoglycemia	Specify with or without coma
.65	Hyperglycemia	Nothing extra required
.9	No complications	Confirm no complications in full chart review

Medication add-on codes

Situation	Code to Add
Any diabetes type (not E10) on insulin	Z79.4
Any diabetes type on oral hypoglycemic agents	Z79.84
On both insulin and oral agents	Z79.4 and Z79.84
Diet-controlled only	No Z code needed
CKD with diabetic nephropathy	N18.1 through N18.6
Foot ulcer present	L97.x
Complication fully resolved	Z86.39

Glossary

These are plain-language definitions for every term used throughout this guide.

Adverse Effect: A harmful reaction to a medication that was prescribed correctly and taken properly. Coded with T-codes.

Angiopathy: Damage to blood vessels. Peripheral angiopathy refers to damage in the small blood vessels of the feet, legs, or hands.

Autonomic Neuropathy: Nerve damage affecting the body’s automatic functions, including heart rate, digestion, and bladder control.

CKD (Chronic Kidney Disease): Gradual, permanent loss of kidney function. Staged from 1 (mild) to 5 (kidney failure requiring dialysis).

ESRD (End Stage Renal Disease): The final stage of kidney failure. The patient needs dialysis or a transplant to survive.

Gangrene: Death of body tissue, usually from loss of blood supply. Must be explicitly documented by the physician to be coded.

HCC (Hierarchical Condition Category): A risk-scoring model payers use to estimate how sick a patient population is and adjust payments accordingly.

HbA1c: A blood test showing average blood sugar over the past 2 to 3 months. It is a monitoring tool, not a codeable diagnosis by itself.

Hyperglycemia: High blood sugar. Coded as .65 when documented in the current encounter.

Hypoglycemia: Low blood sugar. Can cause shaking, confusion, or loss of consciousness.

Macular Edema: Swelling in the center of the retina. A serious diabetic eye complication that affects central vision.

Mononeuropathy: Damage to one specific nerve.

Nephropathy: Kidney damage. Diabetic nephropathy means the kidneys were damaged by chronically high blood sugar over time.

Neuropathy: Nerve damage caused by chronically elevated blood sugar.

Physician Query: A formal written or verbal request asking a physician to clarify a diagnosis or its connection to another condition in the medical record.

Polyneuropathy: Damage to many nerves at once. In diabetes, it typically affects the feet and hands first and is commonly called peripheral neuropathy.

Proliferative Retinopathy: Advanced diabetic eye disease where new, fragile blood vessels grow on the retina. These vessels are prone to bleeding and can cause vision loss.

Retinopathy: Damage to the blood vessels in the retina. One of the most common long-term complications of diabetes.

Risk Adjustment: A process that modifies payments to providers based on how sick their patient population actually is, as reflected in the diagnosis codes submitted.

Sequencing: The order in which codes appear on a claim. The principal or causative diagnosis is listed first.

Z Codes: ICD-10 codes for diabetes that capture health-related factors like medication use, personal history, and family history. They are not diagnoses on their own but add important context to a claim.

Disclaimer

This guide is for educational purposes only and does not replace official ICD-10-CM guidelines, your organization’s compliance policies, or advice from a certified coding professional. Codes and rules are updated every October 1st, so always verify against the current year’s official code set before submitting any claim. The examples in this guide are for learning purposes only. Real coding decisions must be based on the full medical record. The authors accept no liability for errors, denials, or compliance issues arising from use of this material without independent verification.

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New AI CPT Codes in 2026: What They Mean for Your Practice’s Revenue

omni — Wed, 25 Mar 2026 13:04:46 +0000

New AI CPT Codes in 2026: What They Mean for Your Practice’s Revenue

Imagine your busy cardiology practice. Your EHR flags abnormal cardiac scans for AI-assisted review, but your billing team isn’t sure how to code these services. Without proper documentation, revenue could slip through the cracks. With the 2026 CPT updates, OmniMD can help your team integrate AI-assisted workflows seamlessly.

Artificial intelligence is transforming healthcare, helping clinicians analyze data, support diagnoses, and enhance patient care. The American Medical Association (AMA) has introduced new AI-related CPT codes in 2026, officially recognizing AI-assisted services in the Current Procedural Terminology (CPT) system.For U.S. practices, these updates impact documentation requirements, coding workflows, and potential revenue opportunities. Understanding them now is crucial to stay compliant and capture all reimbursable services.

What’s New: AI CPT Codes 2026

The 2026 update introduces AI-augmented CPT codes, which cover clinical services where algorithms analyze data, and physicians provide the final interpretation. These are not codes for the software itself, they are for the AI-assisted service delivered to the patient.

Here’s a snapshot of key AI-specific codes this year:

Cardiology

Coronary Plaque Assessment: AI-assisted analysis of CT angiography to evaluate disease severity.
Perivascular Fat Analysis (0992T, 0993T): AI assessment of cardiac risk, with or without CT imaging.
Noninvasive Arterial Plaque Analysis (0710T): AI-supported analysis of arterial data.
ECG Algorithmic Analysis (0902T, 0903T–0905T): AI detection of atrial fibrillation, murmurs, and reduced ejection fraction.

Pulmonology

CT-Based Interstitial Lung Disease Classification (0877T–0880T): AI-driven diagnostic evaluation from imaging.

Urology

Prostate Estimation Mapping (0898T): AI-assisted mapping for prostate evaluation and surgical planning.

Wound Care

Multispectral Burn Imaging: AI-supported burn classification to guide treatment decisions.

Neurology & DementiaBeta-Amyloid and Tau Testing (82233, 82234, 84393, 84395): New lab codes supporting Alzheimer’s and neurodegenerative disease evaluation.

How AI Codes Differ from Traditional CPT Codes

Unlike traditional CPT codes, which describe an action performed directly by a clinician, AI-augmented codes reflect a collaboration between an algorithm and the provider. The AI analyzes the data, and the clinician interprets and acts on the findings. Both contributions are necessary for billing.

Key differences are summarized below:

Feature / Dimension	AI-Augmented	AI-Automated	Notes / Implications
Clinician Oversight	Required	Minimal/None	Only augmented services with review are billable
Reimbursement	Billable under CPT	Generally non-billable	Correct coding is critical for payment
Documentation	Physician review + AI output	AI-only output	Essential for audits and claim approval
Workflow Impact	Speeds decision-making	Reduces manual tasks but not reimbursable	Augmented improves care quality
Risk / Compliance	Lower if documented	Higher risk	Fully automated services may trigger audits
Clinical Examples	AI-assisted imaging, pathology	AI-only data aggregation	Augmented requires clinician input
Revenue Potential	High	Low	Accurate coding ensures financial benefit
Patient Safety	Maintained / improved	Depends on oversight	Physician ensures AI recommendations are accurate
Training & Adoption	Moderate	Low	Augmented requires clinician training
EHR / Billing Integration	Moderate	Low	Augmented needs proper mapping in billing

Revenue Impact for Your Practice

The new AI CPT codes create real revenue opportunities, but only for practices that prepare properly.

New Revenue Streams
Previously delivered services that weren’t separately billable can now generate reimbursement. Specialties like cardiology, radiology, pulmonology, and urology can see significant gains.

Risk of Denials
Failing to update workflows and documentation puts claims at risk. Payers are auditing AI-assisted services closely. Even small omissions, like missing physician review, can trigger denials.

Remote Patient Monitoring (RPM)
New short-duration RPM codes (as little as 2 days) and reduced management thresholds expand billing opportunities for chronic condition management.

Documentation Requirements You Cannot Ignore

Proper documentation is the biggest compliance challenge for AI billing:

Algorithm Used: Document which AI tool contributed to the service.
Physician Oversight: Note any clinical modifications made.
Final Decision: Record the physician’s clinical judgment.
Vendor Identification: Include the AI vendor/system in the record.
Algorithm Version: For some codes, the software version may be required.

At OmniMD, our EHR and practice management platform captures all these elements automatically, integrating seamlessly into your workflow so providers can focus on patient care.

Specialty-Specific Considerations

Cardiology & Vascular
AI codes for plaque assessment, cardiac risk analysis, and ECG interpretation make cardiology one of the most impacted specialties. Lower extremity revascularization codes were fully rebuilt with 46 new territory based codes.

Radiology
CT cerebral perfusion imaging transitioned to Category I, and AI-assisted radiology billing now has formal support. Charge capture workflows must be updated.

Primary Care & Internal Medicine
New RPM billing codes support short-duration monitoring, benefiting hypertension, diabetes, and heart disease management.

Pathology & Lab
About 27% of new codes fall under Proprietary Laboratory Analyses (PLA), including genomics and specialty diagnostics. Labs and practices must confirm payer recognition.

How We at OmniMD Support Practices

Handling 418 code changes alone is challenging. We at OmniMD provide:

Automated code updates: New, revised, and deleted codes updated in real-time.
AI-specific documentation templates: Capture all required elements effortlessly.
Claim scrubbing: AI-specific checkpoints reduce risk of denials.
Denial management: Track trends and quickly resolve AI-related issues.
Training & compliance support: Ongoing education for your team.
RPM integration: Short duration RPM codes are fully supported.

With OmniMD, your practice can capture AI-assisted revenue from day one while minimizing risk.

Action Checklist

Audit services: Identify AI-assisted procedures your practice already delivers.

Update templates: Ensure documentation captures AI involvement and physician review.
Train staff: Clarify differences between traditional and AI-augmented codes.
Check clearinghouse systems: Confirm they handle new codes and modifiers.
Monitor payer policies: Track CMS and commercial payer guidance.
Assign an AI billing lead: Manage regulatory updates and denials.
Review RPM eligibility: Identify patients eligible for short duration monitoring.
Partner with OmniMD: Let our team guide you through code setup, claims, and denial resolution.

The Bigger Picture

The 2026 CPT updates are just the beginning. The AMA is already reviewing autonomous AI billing applications, where physician work may not be needed at the point of care. Practices that build strong workflows, accurate documentation, and billing partnerships now will have a long-term advantage.

Nearly two-thirds of U.S. physicians use AI tools today. The gap between clinical use and billing capture is where revenue is being lost. The 2026 CPT updates bridge that gap, for practices ready to act.

AI CPT Codes 2026: A New Revenue Opportunity

Understand the latest billing changes and turn AI adoption into real financial growth for your practice.

Talk to Expert