Some payers will take back the fee-for-service payment if the wrong diagnosis code is selected.
There have been many conversations had since the healthcare industry moved to ICD-10-CM, and many more guidelines developed regarding when to query a physician, which has sparked even more debate.
Guideline 19 in ICD-10-CM states:
“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”
But, in fact, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has weighed in on the importance of provider documentation through risk adjustment programs. The italicized excerpts below indicate their review and ongoing work of hierarchical condition category (HCC) coding for Medicare Advantage programs:
From a provider standpoint, we have taken a backseat, being as in most situations regarding risk adjustment coding, our best opportunity for receiving a piece of the pie has been charging for compiling our medical records for review by the managed care associations; remember, we still mainly receive our reimbursements from fee-for-service functions.
So it begs the question, from a provider standpoint, what is in a diagnosis code? We know that we need the right ones in order to get services or procedures approved. We know that the use of them will help us meet certain quality measures. Theoretically, we understand the importance of tying them to the patient journey, and documenting appropriately for compliance, helping establish medical necessity.
What most of us didn’t realize (and now are starting to realize) through contract review and denials or takebacks is that certain health plans are starting to change the language in provider contracts, giving themselves the right to take back the provider’s fee-for-service payment if they select the wrong diagnosis code.
That’s right: if you choose the wrong code, and it happened to hit a risk adjustment model code, and upon audit, your documentation does not hit that level of specificity sought for the condition, you forgo your payment. One contract goes on to say that you also must agree to their proprietary bundling software (you don’t get access to it), and no appeal rights are afforded.
As the language in provider contracts continues to get updated, this issue will continue to grow in importance. Once again, it’s important to not place a lot of value on Guideline 19. It’s important to query providers in the absence of documentation when those codes can influence further payments, outside of fee-for-service functions. It’s important that your documentation reaches the level of specificity found in the code.
Clinical documentation improvement and awareness of the risk adjustment models are extremely important for us, as we move forward. Now is the time to review your documentation to make sure it is robust enough to withstand an audit.
Programming Note:
Listen to Rhonda Buckholtz report this story live during Talk Ten Tuesday today, 10-10:30 a.m. EST.
With the April 1 update, the Centers for Medicare and Medicaid Services (CMS) implemented 80 new PCS codes. To break it down, there are 24
In the FY 2027 Inpatient Prospective Payment System (IPPS) Proposed Rule, the Centers for Medicare and Medicaid Services (CMS) has introduced a notable and potentially
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.
Happy HIP Week! Sign up to win free access to our 2026 Coding Clinic Update Webcast Series! Click here to learn more →
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!
BLOOM INTO SAVINGS! Get 25% OFF during our spring sale through March 27. Use code SPRING26 at checkout to claim this offer.
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
