There should be a strong and healthy relationship between health information management (HIM) and case management and/or utilization review (UR) in every healthcare setting. These functions are part of the revenue cycle, but rarely interact. I believe that UR/case management can be helpful to HIM, and vice versa. My first HIM hospital position was in a teaching hospital. The UR/case management department was located next door, and we engaged in a lot of informal communication.
These departments should chat specifically about the collection of social determinants of health (SDoH) data. The discussion topics should include who is collecting the data, where is it documented, and which data should be coded. The answers will be different in each organization. Payors have initiatives centering on the SDoH, and it should be determined which initiatives are most important to your facility.
Another area of collaboration is medical necessity. Frequently, UR/case management will get pre-authorization for procedures based on a CPT code. It is important for the coders to be aware of which CPT code was pre-authorized. The coders can make the UR/case managers aware if a different procedure was performed. A new authorization may be needed, which could avoid a denial and expedite account payment. Coders may be able to assist UR/case managers when they need to assign a CPT code for a procedure. The interaction between them may also be helpful when assigning diagnosis codes to outpatient claims, if the diagnosis codes for medical necessity fail. Additional documentation may be needed from the provider to pass medical necessity, and UR/case management can learn from this process.
The coders may also utilize the clinical expertise of UR/case management. There are times, as a coder, that you may need some clinical input to your coding. The UR/case management staff may have different clinical backgrounds and be able to assist when clinical expertise is needed – and they can provide this clinical input when clinical documentation integrity staff is not available.
Another area where these professionals can interact is the discharge disposition. Providers may not document the precise type of facility to which the patient is being discharged. For example, consider a skilled nursing facility (SNF), but the patient was discharged to a licensed rehabilitation unit within the SNF. When in doubt regarding the discharge disposition, it is important to contact UR/case management to get the accurate type of facility.
I think it is important to have regular touch-base meetings. UR/case management staff may be aware of new procedures that are being proposed. HIM may communicate problems with provider documentation. Such a meeting provides an opportunity to discuss documentation trends and changes in medical practice. It is another way to informally communicate with the medical staff and keep a finger on the pulse of hospital activity.
UR/case management and HIM are two valuable revenue cycle departments. They can assist each other with their skills.
This week Blue Cross Blue Shield published an article titled “Study suggests AI is boosting hospital billing.” The study was based on data analyzed by
The Centers for Medicare & Medicaid Services (CMS) operates a surveillance platform called the Fraud Prevention System (FPS) that analyzes Medicare claims across the full
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.
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.
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.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
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
