KMAP BULLETIN: FY 2026 Updates to the Medicare Guidelines for Unacceptable Principal Diagnosis Codes

Before October 1, 2025: Billing team must access the CMS 'Definition of Medicare Code Edits v43' document from the CMS website to review the updated list of unacceptable principal diagnosis codes. Update billing system edits to prevent submission of claims with these codes as primary diagnoses. Train coding staff on the new restrictions for external causes of morbidity, manifestation codes, and other unacceptable primary diagnosis codes. Monitor KanCare MCO implementation dates as they may vary from the state effective date.