Medicare Compliance & Reimbursement

And know why the changes are going to matter for Medicare billing.

On October 1, 2024, the Centers for Medicare & Medicaid Services (CMS) will add and/or expand over 250 new ICD-10 diagnosis codes affecting almost every category. In medical oncology alone, there are 63 additions, revisions, or deletions.

In this article, we will delve into the upcoming changes, and touch on how the Medicare Advantage model (Version 28) will be affected.

Take Note of These Hodgkin and Follicular Lymphoma in Remission Additions

ICD-10 2025 has expanded C81.- (Hodgkin lymphoma) to include codes that indicate the patient’s condition is in remission for each subcategory in the group. The new codes follow the same first four characters as the existing Hodgkin lymphoma condition subcategories, but add a 5th character, “A,” to describe the patient’s remission status.

So, you will now code a patient in remission for lymphocyte-depleted Hodgkin lymphoma with C81.3A, while you’ll code a patient with lymphocyte-rich Hodgkin lymphoma that is now in remission with C81.4A.

You’ll see the same revision to the C82.- (Follicular lymphoma) codes. For example, a patient in remission for grade IIIa follicular lymphoma will be coded to C82.3A, while you will use C82.5A for a patient in remission for diffuse follicle center lymphoma.

Check Out These New Remission Status Codes for Other Lymphomas

ICD-10 2025 has also expanded many of the lymphoma code groups to include “in remission” codes for some, but not all, code subcategories. Examples include:

• C83.0A (Small cell B-cell lymphoma, in remission)
• C83.3A (Diffuse large B-cell lymphoma, in remission)
• C84.6A (Anaplastic large cell lymphoma, ALK-positive, in remission)
• C84.7B (Anaplastic large cell lymphoma, ALK-negative, in remission)
• C85.1A (Unspecified B-cell lymphoma, in remission)
• C85.2A (Mediastinal (thymic) large B-cell lymphoma, in remission)

Significantly, the 2025 code set also expands the C86.- (Other specified types of T/NK-cell lymphoma) and C88.- (Malignant immunoproliferative diseases and certain other B-cell lymphomas) groups not only with “in remission” codes, this time indicated with 5th character 1, but also with “not having achieved remission” codes, indicated with 5th character 0. Examples here include such codes as:

• C86.00 (Extra-nodal NK/T-cell lymphoma, nasal type not having achieved remission)
• C86.01 (Extra-nodal NK/T-cell lymphoma, nasal type, in remission)
• C86.10 (Hepatosplenic T-cell lymphoma not having achieved remission)
• C86.11 (Hepatosplenic T-cell lymphoma, in remission)
• C88.20 (Heavy chain disease not having achieved remission)
• C88.21 (Heavy chain disease, in remission)
• C88.30 (Immunoproliferative small intestinal disease not having achieved remission)
• C88.31 (Immunoproliferative small intestinal disease, in remission)

Don’t Miss These New Condition Codes

To add extra specificity to C83.39 (Diffuse large B-cell lymphoma, extranodal and solid organ sites), ICD-10 2025 has also added two new codes:

• C83.390 (Primary central nervous system lymphoma)
• C83.398 (Diffuse large-B cell lymphoma of other extra-nodal and solid organ sites)

Stay Alert to This Major Estrogen Receptor Status Code Overhaul

Lastly, ICD-10 2025 has radically revised the Z17 (Estrogen receptor status) category. Beginning Oct. 1, 2024, you’ll have the following eight codes to accompany Z17.0 (Estrogen receptor positive status [ER+]) and Z17.1 (Estrogen receptor negative status [ER-]):

• Z17.21 (Progesterone receptor positive status)
• Z17.22 (Progesterone receptor negative status)
• Z17.31 (Human epidermal growth factor receptor 2 positive status)
• Z17.32 (Human epidermal growth factor receptor 2 negative status)
• Z17.410 (Hormone receptor positive with human epidermal growth factor receptor 2 positive status)
• Z17.411 (Hormone receptor positive with human epidermal growth factor receptor 2 negative status)
• Z17.420 (Hormone receptor negative with human epidermal growth factor receptor 2 positive status)
• Z17.421 (Hormone receptor negative with human epidermal growth factor receptor 2 negative status)

Understand the Significance of the Change

All these additions and expansions emphasize the importance of specificity and highest-severity documentation. They are also preparing oncology coding for CMS full version 28 model final rule for the CY 2025 reporting period.

Clinical documentation improvement will take a front seat to the changes as you will need to validate the highest specificity available to report truthful diagnosis codes. The adjustments from version 24 to version 28 have already seen a significant decrease in risk adjustment factors with the removal of acute conditions that can be managed by medication and/or are unspecified.

Check back with us in October 2024 as we lay out how these changes will affect the risk adjustment scores for value-based savings.