News
CC/MCC changes in 2027 IPPS final rule: We summarize them for you
The 2027 IPPS final rule includes several CC/MCC reimbursement changes to diagnoses you should be aware of. Watch for these in the documentation and report them and/or query if clinical indicators present. An audit now to confirm their presence or absence is a good strategy. They take effect Oct. 1. For example, hypoglycemia (i.e., low…
Read MoreThe OIG audited 21 specific DRGs—and found heavy error rates with these four
The Office of Inspector General (OIG) released results of three acute care hospital audits with a combined $35M in recommended recoupments. 21 specific DRGs were the target, four of which landed squarely in the bullseye. SVP of Solutions Jason Jobes identified the OIG’s targets, methodology, findings, explained their extrapolation methodology, and offered strategies for risk…
Read MoreOIG offers clinical scenarios that can illuminate your own audit vulnerabilities
The recent Office of Inspector General (OIG) audits of three acute-care hospitals offer a goldmine of clinical/coding examples that you should be using for pre-emptive audit defense. Validating DRG assignments, reviewing medical necessity documentation completeness, and educating providers before an auditor comes knocking—and uses extrapolation to greatly increase recoupments. Here are examples taken from the…
Read MoreInpatient Audit Storm Clouds
Download the report on our resource page. The Office of Inspector General (OIG) never rests. After taking on Medicare Advantage organizations and aggressive risk adjustment coding practices from 2023-2025, the sights of the nation’s regulatory watchdog have shifted. The new target? Acute care hospitals and inpatient admissions. Plus some other outpatient odds and ends. This…
Read MoreTwo reasons why the 2027 OPPS proposed rule hurts your hospital
By Brian Murphy The 2027 OPPS (outpatient) proposed rule landed just prior to the July 4 holiday weekend. CMS’ timing is conspicuous, presumably to dodge the tomatoes hurled at it from the likes of the American Hospital Association. Not a whole lot of great news in here for healthcare orgs; here are two and…
Read MoreYou should be billing G2211 in heavy volume, per CMS
Who remembers G2211? Starting in 2024 this CPT code took the mid-revenue cycle by storm. Despite paying very little ($16.04) it was intended to be used in quantity. It has been. A new study by the Journal of the AMA found that its first year of full use, calendar year 2024, G2211 was billed 26…
Read MoreNew 2027 ICD-10 codes are out (effective Oct. 1)—what you need to know
By Brian Murphy The 2027 ICD-10-CM (diagnosis) and ICD-10-PCS (procedure) codes are out. You can view them on the CMS website at the link below. They take effect Oct. 1, 2026. So what do we have? At a high level: ICD-10-CM: 190 new codes, 30 deletions, 4 code revisions ICD-10-PCS: 101 new codes, 38 deletions,…
Read MoreThe Great Sepsis War rages on; will we see a truce, or a winner?
By Brian Murphy The Great Sepsis War rages on. The infection itself, which kills hundreds of thousands every year, but also in the hallowed halls of coding classification. Where in the A41.9 will we end up with this deadly but controversial infection? (aside: sepsis isn’t funny, but the rage elicited over conflicting definitions and…
Read MoreDownload The State of Physician Queries
Download the report. The old-timers—and perhaps a few relatively recent-timers—will recall a recent past when a query was pretty straightforward. Discrete to the encounter. Fee-for-service. Reimbursement driven. Ask the question, get a response. Dusted and done. Those days are long gone. A query isn’t just a query, anymore. And that’s a good thing. This new…
Read MoreIf a GLP-1 drops your BMI under 35, is morbid obesity off the table?
By Brian Murphy At the ACDIS conference last week, an interesting obesity coding question posed during a Q&A session at the Outpatient Symposium: Should we continue to code morbid obesity for patients who were previously morbidly obese (BMI greater than 35 with obesity-related comorbidities), but because they are on an active GLP-1 their BMI is…
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