Well, it has started happening.
As I feared, there are coders who want to link any and all hypertensive patients who also happen to have chronic heart failure (CHF) and/or renal failure all together.
“So, what is wrong with that?” You may ask.
The problem is that they are doing it even when there is strong evidence in the records that the CHF is being caused by some other problem other than hypertension. The reports I am hearing are that coders and those with coding backgrounds are discounting the opinions of the clinical documentation improvement (CDI) nurses when clinical evidence in the record suggests an alternative cause of the etiology, suggesting the need for a query.
For example: consider a patient who has CHF, hypertension, and chronic kidney disease (CKD), Stage 1, who automatically gets all the dots connected under the new rules. What if the CDI specialist sees that the patient also has aortic stenosis or a longstanding history of atrial fibrillation? Both are conditions that overwork the heart and lead to both cardiomyopathy and CHF.
What if the patient also had a history of some pretty significant coronary artery disease? To the clinically trained, this may represent some confusion about the true etiology of the CHF, as it may be ischemic. There are a myriad of reasons not related to hypertension that could explain why CHF may occur. They range from the congenital to the very slow progressive to the suddenly catastrophic.
When an alternate cause of an etiology exists in a record, the CDI specialist now should be fully aware of the guideline that could push the coding and billing into an ICD-10 code and DRG that may not accurately reflect the clinical truth of the presentation, and that specialist should view a query as fully warranted. Sure, it usually is the hypertension; you will get no argument from me there. And yes, when all things are equal and the physician just isn’t sure, they may be fine with letting it code to the default. However, if the record is confusing enough that the CDI specialist interprets it as unclear, then I encourage the assignment of a clarification query. It doesn’t really matter if the physician ultimately agrees or disagrees, as I expect it could be a 50/50 chance he or she will or won’t in some cases. What matters is that the documentation, once unclear and subject to auditor scrutiny and confusion, is now made clear and transparent.
Don’t take my word for it. As the official guidelines state, the casual relationship should be assumed even in the absence of provider documentation explicitly linking them, “unless the documentation clearly states the conditions are unrelated.” Unfortuately, “clearly” is about as vague as it gets. What is clear to me as a clinician may not be as clear to the auditor or the coder. More importantly, what is confusing for me as a clinician may be seen as low-hanging fruit for auditors looking to deny claims on the basis of clinical validation.
We haven’t heard the last of this. As I mentioned previously, if I ran an audit company right now, I would be counting my extra dollars to come. You can bet they will be attacking this coding guideline when they disagree from a clinical perspective.
The bottom line is that if your CDI specialist thinks they see alternative possible etiologies and the record appears confusing, you have a couple of options: you can allow the query, or you can be prepared to not blame your CDI team or consultant when the denials and penalties start rolling in.
They did, after all, warn you.
For decades, clinical documentation integrity (CDI) programs have been synonymous with inpatient care. They evolved from early efforts to improve Diagnosis-Related Group (DRG) accuracy into
The 2026 Medicare Physician Schedule Final Rule includes several distinct policy changes in which the Centers for Medicare & Medicaid Services (CMS) modifies how it
Please log in to your account to comment on this article.
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.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
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.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Learn how to navigate the proposed elimination of the Inpatient-Only list. Gain strategies to assess admission status, avoid denials, protect compliance, and address impacts across Medicare and non-Medicare payors. Essential insights for hospitals.
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. 2 with code CYBER24
