2025 Medical Coding Updates: Key Changes & Impacts
Staying current with 2025 medical coding updates is essential for healthcare teams. This year has brought notable changes across several key areas:
- Telemedicine Coding: In 2025 there have been 17 new codes introduced for telemedicine to provide a higher specificity in billing.
- Cancer Coding: Codes for neoplasms have greatly expanded to allow for further specificity. Most notably there has been a large increase in codes to demonstrate if a cancer has or has not achieved remission.
- Mental & Behavioral Health: Revisions to dementia and Parkinsonism codes, along with new codes for various mental health conditions, offer greater specificity.
CMS Scrutiny in 2025: Preparing for RADV Audits and Compliance
Another major change seen in 2025 is increased auditing and scrutiny by the Centers for Medicare & Medicaid Services (CMS). The main area of focus in 2025 will have an impact on Risk Adjustment Data Validation (RADV) which affects risk adjustment coding. CMS will be looking closely at overpayments and potential fraud. This means that organizations need to ensure that they are prepared with a very high quality of documentation and accurately coding supported medical conditions. Providers need to ensure that they are clearly documented to the highest level of specificity without any assumptions to ensure they can apply all applicable codes while maintaining a high level of documentation support for each of these conditions. Coders should ensure that documentation is fully and clearly supporting all codes applied and querying providers when more clarification is needed to meet the increased standards coming from CMS.
How has the shift to value-based care changed the role of coders and documentation?
The healthcare industry has made a large shift towards value-based care which drives more of the focus on improving the health of each patient while controlling the costs. This is a shift away from a fee-for-service model in which the reimbursement is focused on paying for each service provided and doesn’t have any focus on the patient’s health condition. This incentivizes providers to deliver higher quality care that is measured through metrics such as patient satisfaction and readmission. This change has also had an impact on medical coding by coders needing to adapt a more comprehensive approach to interpreting documentation. This requires a coder to have a deeper understanding of the clinical workflow and how outcomes are measured. It also requires increased collaboration between medical coders and the clinical team. Essentially value-based care has made coders a more integral part of the revenue cycle, transforming it into a more strategic function from a transactional one. Coders now help to ensure services renders are documented and supported as value to the patient’s care by following evolving guidelines to also support value-based care. A shift to value-based care has also driven an increased usage of AI to support medical coders. AI has been used to help ensure the quality of coding and increased its efficiency ensuring coding aligns with the shifting healthcare landscape.
2025 Mid-Year Check-in:
Trends in Medical Coding & Documentation
Persistent Challenges: Top Clinical Documentation Gaps in 2025
Despite advances in technology and training, clinical documentation gaps remain one of the most persistent challenges in healthcare revenue cycle management.
In 2025, many providers continue to rely on template-driven documentation—dropdowns, auto-filled code descriptors, and pre-populated fields—instead of clearly documenting each patient’s condition and care. While templates help streamline a fast-paced coding environment, they can cause problems. A coder may code too much off templates alone without ensuring there is clinical context for all the codes that are assigned.
Another ongoing challenge is the disconnect between clinical and coding teams. Coders and providers aren’t always aligned on what needs to be documented for accurate ICD-10-CM coding and appropriate reimbursement. That’s why cross-functional education and communication remain critical.
Let’s face it, physicians were trained to diagnose and treat, not to write for coders. As a result, documentation habits often reflect ingrained workflows or how they were originally trained. But in today’s claim-based reimbursement environment, that mindset has to change.
Key Challenges in Documentation:
- Overlooking detailed diagnosis coding (ICD-10-CM): This directly impacts coding accuracy and the ability to capture the full patient story.
- Undocumented chronic conditions and Social Determinants of Health (SDoH): These significantly impact risk scoring and reimbursement.
- Copy-pasting from prior notes: While common, physicians may forget to explain why the information matters for the current encounter.
Why Comprehensive Documentation Matters for Your Organization
Accurate, complete documentation is how physicians tell the full story of the patient. It supports:
- Appropriate coding and risk adjustment
- Continuity of care across encounters
- Audit readiness and regulatory compliance
- Higher-quality performance metrics in value-based care programs
Reframing Medical Decision Making (MDM) for Enhanced Documentation Quality
Many providers mistakenly believe documentation should reflect only the highest level of MDM, but that’s just one piece of the puzzle.
In reality, Medical Decision Making comprises three distinct elements, all of which should be reflected in the note:
- The number and complexity of problems addressed
- The amount and complexity of data reviewed
- The risk of complications or morbidity
When all three elements are documented thoroughly, the result is stronger support for coding, fewer denials, and a clearer picture of the patient’s overall care complexity.
Mid-Year 2025 Check-in: What CSI Experts Are Seeing Across Healthcare Organizations
Top Pain Points Holding Healthcare Organizations Back
Healthcare organizations are facing a convergence of challenges that are putting pressure on both coding accuracy and operational efficiency:
- Rapid guideline and code set changes: Frequent updates and revisions (like CPT 2025 updates, ICD-10-CM changes and new telemedicine codes introduced in 2025) make it difficult for medical coders to stay aligned.
- Ongoing medical coder shortages: The demand for experienced, credentialed coders continues to outpace supply, leading to high turnover and operational gaps.
- Burnout among coders and providers: With staffing stretched thin, teams are focused on volume rather than quality—resulting in documentation shortcuts, decreased accuracy, and rising frustration.
This reactive environment, often driven by the pressure to “just get the billing out the door,” can erode coding quality and ultimately impact patient care and financial performance.
The Organizational Impact: Denials, Delays, and Missed Opportunities
Organizations that have not adapted to the 2025 coding landscape are seeing a spike in:
- Claims denials
- Delayed reimbursement
- Reduced patient satisfaction
The root cause? A lack of preparation around new guidelines, insufficient coder education, and poor alignment between documentation and coding practices.
On the other hand, healthcare systems that invested in proactive readiness, by updating internal processes, training teams, and aligning with value-based care models are reaping measurable benefits:
- Improved coding quality and revenue efficiency
- Better patient outcomes
- Greater financial stability
Trends Shaping 2025: Advanced AI, Purposeful Documentation, and Telehealth
CSI experts are tracking several key developments that are influencing the direction of medical coding and documentation:
The Expanding Role of AI in Medical Coding and Documentation
Artificial Intelligence (AI) is becoming more integrated across the revenue cycle. In coding, AI is helping boost accuracy and speed—while simultaneously improving documentation quality and enabling smarter treatment decisions. Still, successful adoption depends on pairing AI tools with well-trained human oversight. The integration of Artificial Intelligence (AI) into medical coding is something all healthcare organizations should stay up to date on. While AI cannot replace the need for human interpretation and application of codes, its capabilities are rapidly advancing. This includes the rise of sophisticated Large Language Models (LLMs). AI tools have the ability to be utilized across many areas of patient care and the revenue cycle, particularly in medical coding, where they can increase the quality of coding and improve medical documentation, leading to better patient treatment plans.
The Shift Toward Purposeful Documentation
There’s a growing industry emphasis on quality over quantity when it comes to documentation. Organizations are prioritizing physician education on how to document with intent—ensuring that notes reflect the full clinical picture, support coding specificity, and enhance continuity of care.
Telehealth is Reshaping Documentation Norms
The continued rise of telehealth is transforming how providers document encounters. Virtual care requires unique coding considerations and a fresh look at how medical decision-making is conveyed. Healthcare organizations must adapt quickly to maintain compliance and reimbursement accuracy in this evolving space.
Driving Success in 2025: The Impact of High-Performing CDI Programs
In 2025, top-performing Clinical Documentation Integrity (CDI) programs are transforming how healthcare organizations approach documentation, coding accuracy, and audit preparedness. Rather than acting as a reactive function, today’s CDI teams are proactively engaging with both coders and clinicians before claims are submitted, ensuring real-time opportunities for education and documentation improvement. This proactive approach helps coders adapt to a more comprehensive interpretation of documentation, requiring a deeper understanding of clinical workflow and how outcomes are measured.
Key drivers of success include:
- Risk adjustment (HCC) alignment: Strong CDI teams are deeply integrated with value-based care strategies, helping organizations maximize appropriate reimbursement while maintaining compliance.
- Clinical expertise at the core: Effective CDI specialists bring a high level of clinical knowledge, allowing them to review encounters with depth and deliver more relevant, timely queries.
- Continuous education: By working hand-in-hand with physicians, CDI teams foster better documentation habits that reduce denials and improve overall data quality.
In parallel, high-performing coding programs are strengthening their collaboration with CDI teams, recognizing the shared goal of improved documentation, cleaner claims, and audit readiness. Organizations that prioritize regular coder education, internal and external audits, and feedback loops are seeing measurable gains in both coding quality and operational efficiency.
How CSI Elevates coding and Documentation Excellence
At CSI, we combine deep clinical expertise with hands-on coding and documentation experience to help healthcare organizations thrive in a highly regulated, value-based landscape.
Our approach includes:
- A team of seasoned CDI specialists selected for both their documentation knowledge and clinical insight ensuring the highest quality review and physician advising from the start of the revenue cycle.
- Coding leadership with real-world, multi-level experience, offering coders not only strategic direction but also meaningful mentorship and support.
- A strong commitment to ongoing coder education, compliance training, and performance auditing to uphold the highest standards of accuracy, consistency, and regulatory alignment.
We don’t just help organizations keep up we help them lead. With CSI, providers and coders are equipped with the tools, guidance, and support to deliver quality outcomes, clean claims, and sustainable revenue performance. Explore CSI’s comprehensive clinical documentation integrity and medical coding solutions to learn how our expert team can support your success in this evolving healthcare landscape.
