From LOS to CC 44 and the Pepper Report, important news, and updates.
Last week was (thankfully) a boring regulation week. So instead of working to interpret new rules, I was able to do some real work. These last few weeks I have been working on the third edition of my book that I am co-authoring with Stefani Daniels on Hospital Utilization Review. Some of you may know Stefani- she has been working in case management for a very long time. She has helped many hospitals redesign their case management program over the years. To tell you Stefani’s devotion to her work, she first told me in 2017 that she is retiring yet here we are in 2021 collaborating. One of the other reasons I like Stefani is that she agrees with me that length of stay is a terrible metric. Anyways, as I was writing sections, I got to the condition code 44 section. The bulk of the section required no edits since the Medicare condition code 44 process has not changed since 2004 and I was going to move on but then I recalled the RACmonitor article by Dr Juliet Ugarte Hopkins on condition code 44. Reading that article was a huge “aha” moment for me. That article made me realize that condition code 44 was just a number and not a process and we had all been misinterpreting it. So the book now has an in-depth explanation of condition code 44 as it applies non-Medicare payers. Now if you don’t recall reading that article on RACmonitor news, look it up and read it or even better wait until fall and buy a copy of the third edition of the Hospital Guide to Contemporary Utilization Review.
Last week I did a review of a health system’s latest PEPPER. This system had several measures where they were a low outlier. Now being a low outlier is good in that no auditor will waste their time with you, but you must decide if maybe you are too conservative and leaving money on the table. Are you doctors documenting thoroughly or do you need to call Dr. Erica Remer for a chart audit and education? The concern was that this system had an academic medical center and really sick patients. On the call, the physician advisor asked a very interesting question. What if they were doing everything right but many other hospitals were ignoring the rules? How profound. And other data in the PEPPER may support that. The PEPPER data shows that about 20 percent of hospitals in the nation did all their Medicare total knee arthroplasties as inpatient from 2018 to 2020 when it was no longer inpatient only. Do all their patients require a stay over two days or are they all at high risk or were they admitting all as inpatient because no one was auditing?
There are over 5,000 hospitals in the country. There are hundreds of compliance areas where hospitals can stretch the rules or even totally ignore them. And when they do that, the hospitals that are following the rules have their data look like they are underperforming. This goes back to what I said at the beginning- that length of stay is a terrible measure. Likewise, I dislike the term “benchmark rate.” Whose benchmark? Whose data contributed to that benchmark? If the benchmark consists of those hospitals that are flaunting the regulations, is that really the goal you want to attain?
Programming Note: Listen to Dr. Ronald Hirsch conduct his Monday rounds during Monitor Mondays, 10 Eastern, sponsored by R1 RCM.
It is a bummer when you get hoisted on the petard of intellectual inconsistency. Whether it is different medical professionals with different approaches to a
In a recent article, I described a documentation environment governed by two distinct and often competing controlling systems. The first is the regulatory framework established
Please log in to your account to comment on this article.
Sepsis sequencing continues to challenge even experienced coding and CDI professionals, with evolving guidelines, documentation gaps, and payer scrutiny driving denials and data inconsistencies. In this webcast, Payal Sinha, MBA, RHIA, CCDS, CDIP, CCS, CCS-P, CCDS-O, CRC, CRCR, provides clear guideline-based strategies to accurately code sepsis, severe sepsis, and septic shock, assign POA indicators, clarify the relationship between infection and organ dysfunction, and align documentation across teams. Attendees will gain practical tools to strengthen audit defensibility, improve first-pass accuracy, support appeal success, reduce denials, and ensure accurate quality reporting, empowering organizations to achieve consistent, compliant sepsis coding outcomes.
Expert presenters Kathy Pride, RHIT, CPC, CCS-P, CPMA, and Brandi Russell, RHIA, CCS, COC, CPMA, break down complex fracture care coding rules, walk through correct modifier application (-25, -57, 54, 55), and clarify sequencing for initial and subsequent encounters. Attendees will gain the practical knowledge needed to submit clean claims, ensure compliance, and stay one step ahead of payer audits in 2026.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
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.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
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
