Guideline updates:
Corresponding to these new codes, ICD-10-CM guidelines also received updates to clarify their use:
- Obesity class codes: Under subcategory E66.81, coders must assign a fifth character to indicate the severity.
- Obesity and BMI documentation: BMI codes (Z68.-) should be assigned only when an associated, reportable diagnosis (like obesity or anorexia) is documented. For fluctuating BMI during an encounter, the code for the most severe value should be assigned.
Social determinants of health (SDoH): Expanded coding options for insufficient health insurance and welfare support help track socioeconomic factors that affect patient care
The ICD-10-CM Z-code categories capture various social determinants of health (SDoH). These codes provide information on socioeconomic and psychosocial circumstances that can impact a person’s health. The following is a detailed list of the Z-code categories and some of their key sub-codes, including updates effective October 1, 2025.
1. Education and literacy (Z55)
- 0: Illiteracy or low-level literacy.
- 1: Schooling unavailable or unattainable.
- 5: Less than a high school diploma.
- 6: Problems related to health literacy.
2. Employment and unemployment (Z56)
- 0: Unemployment, unspecified.
- 1: Change of job.
- 2: Threat of job loss.
- 82: Military deployment status.
3. Occupational exposure to risk factors (Z57)
This category includes exposure to various risks such as noise (Z57.0), radiation (Z57.1), dust (Z57.2), and toxic agents in other industries (Z57.5).
4. Physical environment (Z58)
This category addresses issues like inadequate drinking-water supply (Z58.6) and unavailable basic services (Z58.81).
5. Housing and economic circumstances (Z59)
This category, which saw significant updates in FY 2026, is a crucial SDoH category. It includes codes for homelessness (Z59.0), inadequate housing (Z59.1), lack of adequate food (Z59.4), extreme poverty (Z59.5), insufficient health insurance (Z59.71), insufficient welfare support (Z59.72), transportation insecurity (Z59.82), and financial insecurity (Z59.86).
6. Social environment (Z60)
This category covers problems like living alone (Z60.2), acculturation difficulty (Z60.3), social exclusion (Z60.4), and experiencing adverse discrimination (Z60.5).
7. Upbringing (Z62)
This category includes current and past negative childhood experiences, such as inadequate parental supervision (Z62.0), parental overprotection (Z62.1), and a history of abuse in childhood (Z62.81-).
8. Primary support group (Z63)
This category addresses problems in relationships with a spouse or partner (Z63.0), absence of family members due to military deployment (Z63.31), and the disappearance or death of a family member (Z63.4).
9. Other psychosocial circumstances (Z64–Z65)
This category includes issues related to imprisonment (Z65.1), problems after release from prison (Z65.2), being a victim of crime (Z65.4), and exposure to disaster or conflict (Z65.5).
Payer-specific policy changes
1. Cigna’s E/M down-coding policy (R49): Temporarily paused implementation following industry backlash, but has not been permanently withdrawn.
E/M down-coding policies
Payers are intensifying scrutiny on Evaluation and Management (E/M) claims, especially for higher-level services.
- Cigna (R49 Policy):
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- Status: Temporarily paused.
- Reason for pause: Significant pushback and advocacy from medical boards and associations.
- Previous action: Was planned to go into effect on October 1, 2025, and would have involved automated down-coding of E/M services.
2. Aetna’s E/M down-coding: Ongoing retrospective audit process continues in more states, scrutinizing high-level E/M services.
- Status: Ongoing, active, and expanded as of September 1, 2025.
- Process: Utilizes retrospective audits to review claims for correct coding and may recoup payments for services paid at a lower level.
- Impact: Places a greater administrative burden on providers to appeal down-coded claims.
3. Provider best practices: It is still recommended to maintain meticulous documentation for E/M visits, focus on medical decision-making (MDM) elements, and be prepared to appeal denials.
4. Prior authorization reforms: Over 50 major U.S. insurers committed to streamlining the prior authorization process, with changes expected in 2026.
The Centres for Medicare & Medicaid Services (CMS) is implementing major changes to prior authorization rules that will affect most payers.
- Prior authorisation mandate: The CMS Interoperability and Prior Authorisation Final Rule requires Medicare Advantage plans, state Medicaid, and CHIP programs to streamline their prior authorisation processes.
Upcoming updates for 2026
The American Medical Association (AMA) released the CPT 2026 code set on October 2, 2025, with an effective date of January 1, 2026.
- 288 new codes: Introduced for new medical, surgical, and diagnostic services.
- Digital health and AI: New codes reflect advancements in digital health, telemedicine, and the integration of AI into clinical workflows.
- Expanded E/M codes: Includes codes for new telemedicine services and remote monitoring.