H.R. 1 Impact on Coding
Timothy Powell, CPA, CHCP
December 15, 2025
H.R. 1 doesn’t directly rewrite ICD-10 or CPT, but it does change the environment in which you’re coding. The impact is mostly indirect – through
This week, I’m stepping away from my usual updates on the Social Determinants of Health (SDoH) to share a deeply personal experience. I hope that by bringing this issue to light, we can foster collective growth and learning.
Although I typically keep my personal medical journey private, recent events have compelled me to speak out.
In January 2019, I was diagnosed with Stage 3 Hodgkin lymphoma. Since then, I’ve undergone various treatments, including a stem-cell transplant. Fortunately, for the past two years, a drug called Keytruda has helped keep my cancer at bay, with minimal side effects and significant remission. However, about a month ago, I was blindsided by a denial from my insurance company. The denial came because I had reached the two-year mark on Keytruda, which is the period the insurance company deemed sufficient.
This decision was not only surprising but also disheartening. Despite significant help in filing an appeal from Dr. Kendall Smith at PayerWatch, and my husband, Ryan O’Hara, spending over 18 hours on calls with CareFirst BlueCross BlueShield and CVS Caremark, and presenting evidence from recent studies, my efforts to overturn this denial have been unsuccessful. The insurance company has opted to rely on a four-year-old clinical study rather than the most recent research, which demonstrates that Keytruda continues to be effective, with a 22-percent full remission rate as of Sept. 7, 2023.
The denial of lifesaving treatment by these for-profit entities is a stark reminder of the challenges many face in accessing necessary healthcare. This is not merely about my personal treatment, but a broader issue affecting countless individuals. My oncologist, a respected expert at Mayo Clinic, has prescribed this treatment based on its proven effectiveness and cost-efficiency. Yet, it appears that my insurance has prioritized cost savings over long-term healthcare effectiveness.
As someone who obviously works in the healthcare field, I am familiar with the complexities of navigating this system. I am actively working on alternative plans, but this situation demonstrates a harsh reality: many people lack the resources or knowledge to advocate for themselves effectively. This denial of care, despite my access to support and expertise, raises serious questions about how patients without such resources cope with similar challenges.
The frustration of dealing with an insurance company that seems more concerned with cutting costs than saving lives is compounded by the personal stakes involved. This is not just about me; it’s about the broader issue of insurance companies dictating the terms of care, often while overriding the recommendations of dedicated medical professionals.
In sharing my story, I hope to shed light on this critical issue and encourage a dialogue about the need for systemic change. No one should have to fight for access to lifesaving treatment, and no healthcare decision should be driven by profit rather than patient welfare. The goal should always be to ensure that every patient receives the care they need.
References:
Armand P, Zinzani PL, Lee HJ, Johnson NA, Brice P, Radford J, Ribrag V, Molin D, Vassilakopoulos TP, Tomita A, von Tresckow B, Shipp MA, Herrera AF, Lin J, Kim E, Chakraborty S, Marinello P, Moskowitz CH. Five-year follow-up of KEYNOTE-087: pembrolizumab monotherapy for relapsed/refractory classical Hodgkin lymphoma. Blood. 2023 Sep 7;142(10):878-886. doi: 10.1182/blood.2022019386. PMID: 37319435; PMCID: PMC10624931
EDITOR’S NOTE:
The opinions expressed in this article are solely those of the author and do not necessarily represent the views or opinions of MedLearn Media. We provide a platform for diverse perspectives, but the content and opinions expressed herein are the author’s own. MedLearn Media does not endorse or guarantee the accuracy of the information presented. Readers are encouraged to critically evaluate the content and conduct their own research. Any actions taken based on this article are at the reader’s own discretion.
H.R. 1 doesn’t directly rewrite ICD-10 or CPT, but it does change the environment in which you’re coding. The impact is mostly indirect – through
In the CY 2026 Physician Fee Schedule (PFS) Final Rule, the Centers for Medicare & Medicaid Services (CMS) made significant changes to the applicable use
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.
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
