Well, it appears I opened a real can of worms last week when I mentioned a DRG downgrade audit finding received by a hospital for which the auditor noted that the query was leading. Two Monitor Mondays listeners asked two great questions.
First, Joe asked if there was a law or regulation that prohibits leading queries – and although you could not see it, healthcare attorneys David Glaser and Knicole Emanuel both noted in our internal chat that no such law or regulation exists.
I then had an online discussion with Dr. Erica Remer, and she in turn added that some of her clinical documentation integrity (CDI) colleagues agree that there is no such law. But that does not mean you have carte blanche to produce leading queries. Dr. Remer addressed this on Talk-Ten-Tuesdays (you can listen here) and with an article on ICD10monitor, and the American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Specialists (ACDIS) have released their guideline on compliant queries.
Who knew that healthcare billing and coding could be so complex? And to address David Glaser’s other chat comment, worms used as bait for fishing used to be sold in cans. When the fisherman opened the can, the worms would start wiggling and escape from the can. That led to the fisherman scrambling to catch them all.
Moving on, last week First Coast Service Options (FCSO), the Medicare Administrative Contractor (MAC) that serves Florida, issued a notice that they are seeing an increasing number of claims for anesthesia services provided to patients who were receiving epidural injections or facet joint injections.
Their medical directors feel that anesthesia is not needed for these procedures, and as they said, if the patient has “needle phobia,” an oral anxiolytic should suffice. Is FCSO correct? Well, I admit that I have not done a literature search on the topic, but it seems that if patients managed to receive their injections without the services of an anesthesiologist in past years, why would it be necessary now? Was there a change in the injection technique that now warrants having an anesthesiologist? Is there new data on the risk of injections performed without anesthesia? I recall some of my first colonoscopies, and way back then, the gastroenterologist not only did the scoping, but they also supervised the nurse providing IV sedation. Now, it is routine to have an anesthesiologist. It certainly makes the procedure more comfortable for the patient, and the gastroenterologist can perform more procedures if they do not need to monitor the patient. The same argument could be made for cataract extraction. What role does patient comfort and efficiency play in deciding if a service is necessary? That’s a question I won’t touch.
Finally, UnitedHealthcare (UHC) released their new policy on observation services. But the old policy is really no different than the new policy. Once again, they say that observation is time-limited…but then the policy goes on to say that at that point, their medical director will determine if the patient warrants “an inpatient level of care.” How infuriating. “Inpatient” is not a level of care. The care provided to inpatients is the same as that provided to observation patients. “Inpatient” is a status, and it is appropriate for the patient who hits the end of the time allotted for observation but still requires ongoing hospital care. Now, if they want to say that the ICU level of care is not appropriate or telemetry is not appropriate, or even that hospital care is not appropriate, that is perfectly reasonable. But playing these games about inpatient and observation really must stop.
Programming note: Listen to Dr. Ronald Hirsch live as he makes his Monday Rounds on Monitor Mondays, 10 a.m. EST and sponsored by R1-RCM.
When you hear about pixels, you might think of computer screens – the smaller the pixels, the better the image. Or you might think of
They say artificial intelligence (AI) will improve medicine. But how good is it? Recently, several independent studies tested the leading AI systems, including the PrIME-LLM
Please log in to your account to comment on this article.
Breast biopsy procedures may be clinically straightforward but accurately translating them into compliant billing can be anything but. In this focused webcast, Shawn Blackburn, CPC, CPMA, CIC, CRC, CCS-P breaks down how imaging guidance, lesion count, laterality, and payer expectations all impact how these procedures should be reported. Through clear explanations and real-world scenarios, you’ll gain practical insight into aligning clinical workflows with billing requirements, avoiding common pitfalls, and ensuring your documentation supports accurate reimbursement and compliance.
Gain clarity and confidence in OB‑GYN coding with this expert‑led webcast featuring Sherri L. Clayton, RHIT, CSS. You’ll learn how to apply global maternity package rules accurately, select the right CPT codes for procedures and visits, and identify documentation gaps that lead to denials. With practical guidance and real examples, this session helps you strengthen compliance, reduce audit risk, and ensure accurate reimbursement for women’s health services.
Uncover essential coding insights with nationally recognized coding authority Kay Piper, RHIA, CDIP, CCS. Through ICD10monitor’s interactive, on‑demand webcast series, Kay walks you through the AHA’s 2026 ICD‑10‑CM/PCS Quarterly Coding Clinics, translating each update into practical, easy‑to‑apply guidance designed to sharpen precision, ensure compliance, and strengthen day‑to‑day decision‑making. Available shortly after each official release.
Uncover critical guidance on the ICD-10-CM/PCS code updates. Kay Piper reviews and explains ICD-10-CM/PCS coding guidelines in the AHA’s fourth quarter 2026 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
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.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Celebrate Lab Week with MedLearn! Sign up to win one year of our Laboratory All Access Pass! Click here to learn more →
Have a Medicare regulation question you’d love Dr. Hirsch to answer? Now is your chance! CLICK HERE to learn more→
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
