Hospitals have spent years responding to medical necessity denials after the claim has already been submitted. Appeals are written, peer-to-peers are completed, payer trends are
EDITOR’S NOTE: Senior healthcare analyst Frank Cohen begins a three-part series about auditing in the algorithmic environment. Something has changed in healthcare compliance, and if
I am not a fan of case mix index (CMI) as a key performance indicator for clinical documentation integrity (CDI) departments. A 2022 ACDIS white
One of the most common questions we hear from coding professionals today is simple: Will artificial intelligence (AI) replace coding jobs? It’s an understandable concern.
Fraud, and especially healthcare fraud, has been a frequent topic in the news lately. If you are active on LinkedIn, I encourage you to follow
Under PAMA regulations, how is pricing determined for new laboratory test codes that do not yet have established Medicare payment rates?
What distinguishes a Type 2 MI from a Type 1 MI, and how does it typically present on ECG?
When an attempted lower extremity intervention is unsuccessful, should only the catheterization and diagnostic angiography be coded, or can the attempted intervention also be reported?
Can we use the time in and out of the department to calculate billable units of service for respiratory rehabilitation service codes?
When is CPT® add-on code +0993T reported for augmentative software analysis performed with a CT scan of the heart? Case Example: A patient with multiple cardiovascular risk factors, including obesity, hypertension, a history of smoking, and elevated inflammatory markers, underwent coronary CT angiography (CCTA) for evaluation of coronary artery disease. The patient was placed supine in the CT scanner, and a gated coronary CT angiography study was performed using standard institutional protocol with intravenous contrast. Image quality was confirmed adequate for diagnostic review. Immediately following image acquisition, the CCTA dataset was transferred to an AI-powered perivascular fat analysis platform. The software automatically identified the coronary arteries, extracted perivascular fat regions, and calculated vessel-specific fat attenuation index (FAI) measurements associated with coronary vascular inflammation. Clinical risk factors, including body mass index (BMI), smoking history, high-sensitivity C-reactive protein (hs-CRP), and blood pressure, were incorporated into the software analysis to refine the inflammation-based risk assessment. The platform generated a comprehensive cardiac inflammation profile that integrated coronary plaque characteristics with biologic inflammatory markers. The interpreting cardiologist reviewed both the primary CCTA findings and the AI-generated FAI metrics. The combined report concluded: (1) no obstructive coronary artery disease, (2) mixed noncalcified plaque within the proximal left anterior descending (LAD) artery, and (3) elevated FAI values indicating increased vascular inflammatory activity. Based on these findings, therapy intensification was recommended.
Biliary drainage complexities will not cease in 2026, and with reimbursement and resources tightening because of final rules and economic turmoil, now is a critical
The Centers for Medicare & Medicaid Services (CMS) proposed a rule intended to reduce what it describes as excessive state payment practices, and to redirect
Medicare regulations are complex and even seasoned professionals struggle to apply them consistently. Due to overwhelming demand, Dr. Hirsch returns for Part 2 of Ask Dr. Hirsch: Clarifying Medicare’s Most Misunderstood Rules to answer even more of Medicare’s most misunderstood questions, covering inpatient status, observation, SNF access, Medicare Advantage denials, and more. Join Dr. Hirsch as he provides clear, referenced answers to real-world questions submitted by your peers, helping you navigate Medicare compliance with confidence and clarity.
Traditional utilization management models can no longer keep pace with regulatory shifts, payer scrutiny, and operational pressures. In this webcast, Tiffany Ferguson, LMSW, CMAC, ACM, ACPA-C, introduces an Adaptive Model strategy that modernizes UM through role specialization, technology-driven workflows, and proactive, team-based processes. Attendees will learn how to restructure programs to improve efficiency, strengthen clinical collaboration, and enhance financial performance in a rapidly changing healthcare environment.
Federal auditors are intensifying their focus on inpatient psychiatric facilities, using advanced data analytics to spotlight outliers and pursue high‑dollar repayments. In this high‑impact webcast, Michael Calahan, PA, MBA, Compliance Officer and V.P., Hospital & Physician Compliance, breaks down what regulators are really targeting in IPF-PPS admissions, documentation, treatment and discharge planning. Attendees will learn practical steps to tighten processes, avoid common audit triggers and protect reimbursement and reduce the risk of multimillion-dollar repayment demands.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Artificial intelligence is rapidly transforming healthcare revenue cycle operations, from coding and auditing to compliance and denials. Join industry leaders Pam Warren (MaineHealth) and Raemarie Jimenez (AAPC) for a live fireside chat exploring how AI is changing workflows, workforce roles, payer-provider dynamics, and compliance risk—and what organizations should be doing now to prepare.
Prepare for FY 2027 IPPS changes with a comprehensive 3-part masterclass covering ICD-10-CM/PCS updates, MS-DRG shifts, NTAPs, compliance risks, and reimbursement strategies.
Stay ahead of FY 2027 reimbursement changes with expert analysis of MS-DRG shifts, NTAP updates, Medicare Code Edits, and emerging technologies impacting inpatient payment accuracy.
Stay ahead of FY 2027 ICD-10-PCS changes with expert analysis of new procedure codes, revised guidelines, and high-impact updates affecting reimbursement, compliance, and inpatient coding accuracy.
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