08/20/2025

Looking Forward to 2026: What CDI Leadership Needs to Know

The biggest impacts to clinical documentation integrity (CDI) professionals for the 2026 fiscal year (FY) will not be associated with updates to the ICD-10-CM code set or the Inpatient Prospective Payment System (IPPS).

The biggest impacts will have to do with impending policy changes to Medicare and Medicaid. In my last article, I discussed Medicaid and uninsured patient volumes. This week, I want to discuss another threat to hospital patient volume: changes in the Medicare Inpatient-Only List.

The proposed OPPS rule for 2026 states, “For CY 2026, we propose to phase out the IPO List over three years, beginning with the removal of 285 mostly musculoskeletal services for CY 2026. (p. 16).” Currently there are approximately 1,731 services on the IPO. The factors being used to determine which procedures should be removed from the IPO List include:

• Most outpatient departments are equipped to provide the service or procedure to the Medicare population;
• The simplest service or procedure described by the code may be performed in most outpatient departments;
• The service or procedure is related to codes that CMS has already been removed from the IPO;
• CMS determines that the service or procedure is being performed in numerous hospitals on an outpatient basis; and
• CMS determines that the service or procedure can be appropriately and safely performed in an ambulatory surgical center (ASC), and is specified as a covered ambulatory surgical procedure, or CMS has proposed to specify it as a covered ambulatory surgical procedure.

The proposed rule acknowledges that it will generally be less expensive to provide these services in the outpatient setting, compared to the inpatient setting. As CDI professionals, we know surgical MS-DRGs pay higher than medical MS-DRGs, and as operating margins continue to tighten, the loss of surgical volume could be problematic for many hospitals.

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