Big news to end the year.
The final Monitor Mondays broadcast of the year is normally when I announce my Hirsch’s Heroes. But this year, it would be inappropriate to single out any individuals, when so many in healthcare go to work every day as heroes – and so many have made the ultimate sacrifice. So let’s hope that next year I will be able to resume the tradition.
Moving on to news, boy was there a lot last week. First, the third-quarter Program for Evaluating Payment Patterns Electronic Report (PEPPER) was released last week, and it was notable for two things. First, it is the first PEPPER issued during the COVID pandemic. I’d urge you to use caution interpreting your report, since the pandemic has clearly affected patient acuity around the county. Second, there is a new measure showing the percentage of total knee arthroplasties done as inpatient. And that data is fascinating in that it shows that at least 20 percent of hospitals in the nation are still doing every knee replacement as inpatient. I will remind you that knee replacement was taken off the Medicare Inpatient-Only list three years ago, so at any time, the Recovery Audit Contractors (RACs) can ask the Centers for Medicare & Medicaid Services (CMS) for permission to start auditing these admissions for proper status and start denying claims. In case you don’t know, the RACs are already approved to audit for medical necessity for both hip and knee replacement, and are actively auditing charts. If there is any bright side to this, I’ll remind you that the status audits can only look back six months, so you will have time to rebill for Part B payment if you are denied.
Speaking of status, by now you probably know that CMS finalized its proposal to eliminate the Inpatient-Only list over the next three years, and started by removing 300 procedures, effective Jan. 1, including all orthopedic and spine procedures. But at the same time, they also have put an indefinite moratorium on denials of these surgeries for improper status. They proposed a two-year moratorium, so it was shocking to see them adopt this much more lenient standard. They have stated that the moratorium will be lifted once at least 50 percent of all surgeries are performed as outpatient. My jaw dropped when I read this – no denials? Really? Well, first, the Quality Improvement Organizations (QIOs) will be able to audit, and although they cannot deny, they will provide education. It is not known if they will follow the probe-and-educate process and repeat audits if they find a high error rate on these surgeries, or report their findings to CMS. Second, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has added short stays to its work plan, and the OIG can audit anyone at any time – and they love to extrapolate, as the Uniform Program Integrity Contractors (UPICs) are always watching data for patterns of improper payments.
So, what does this mean? As of now, if a surgery is not on the Inpatient-Only List, you have to follow the two-midnight rule. And remember, despite what you may hear, there is more to the two-midnight rule than a patient spending two midnights in the hospital. Finally, on this topic, right now hopefully all of you review all one-day inpatient stays for compliance with the two-midnight rule. You need to decide if you should add one-day inpatient surgeries to this process, and determine which can be billed as inpatient and which should be rebilled to Part B.
CMS also added 266 procedures to the list of surgeries that can be performed at ambulatory surgery centers (ASCs), including things like infusion of cerebral thrombolytic therapy and robotic prostatectomy. I took a look at the approved payments for prostatectomy, and as outpatient at the hospital, the base payment is $8,900, but at the ASC, it only pays a facility fee of $3,800. I am not sure that $3,800 even covers the supplies to use the robot. I’ll also note that the press releases from CMS stress how all these ASC approvals will lower costs for beneficiaries, but they neglect to note that for 150 surgeries, the out-of-pocket costs for patients will be higher in an ASC than at the hospital.
Programming Note: Ronald Hirsch, MD is a permanent panelist on Monitor Mondays. Listen to his live reporting when Monitor Mondays returns on Monday, Jan. 11, 2021, 10 a.m. EST.
There is a lot of talk lately about the need to follow orders given by a member of law enforcement. I would like to explore
Remember the backlog at the Administrative Law Judge (ALJ) level of review? Where providers routinely waited years for hearings, while recoupments proceeded and cash flow
Please log in to your account to comment on this article.
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.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
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.
As AI reshapes healthcare compliance, the risk of biased outputs and opaque decision-making grows. This webcast, led by Frank Cohen, delivers a practical Four-Pillar Governance Framework—Transparency, Accountability, Fairness, and Explainability—to help you govern AI-driven claim auditing with confidence. Learn how to identify and mitigate bias, implement robust human oversight, and document defensible AI review processes that regulators and auditors will accept. Discover concrete remedies, from rotation protocols to uncertainty scoring, and actionable steps to evaluate vendors before contracts are signed. In a regulatory landscape that moves faster than ever, gain the tools to stay compliant, defend your processes, and reduce liability while maintaining operational effectiveness.
Get clear, practical answers to Medicare’s most confusing regulations. Join Dr. Ronald Hirsch as he breaks down real-world compliance challenges and shares guidance your team can apply right away.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
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
