Alzheimer’s disease is a currently irreversible brain disorder that progressively degrades memory, cognitive function, and the ability to carry out tasks of daily living. It is the number one cause of dementia in older Americans, contributing to 60-80 percent of cases.
On Jan. 11, 2022, the Centers for Medicare & Medicaid Services (CMS) approved the high-profile drug Aduhelm for treatment of Alzheimer’s disease. However, this coverage policy was released with certain specific circumstances in which the drug may be used.
Over 6 million older Americans have Alzheimer’s disease; this prevalence is expected to rise to 14 million by 2060, barring effective interventions (such as lifestyle changes, treatment of risk factors, and possible combinations of drugs). It is the sixth-leading cause of death in the United States. Though concerns have been raised over the accelerated approval of the drug Aduhelm, the anticipation of its availability is certainly no surprise, considering the statistics.
Aduhelm gained attention in 2021 as the first monoclonal antibody for treating Alzheimer’s disease. Not only did the treatment draw attention to the Food and Drug Administration (FDA) approval process (and the speed at which it was gaining momentum), but the initial established list price was also $56,000, raising the Medicare premium by $22 for 2022. In December, this price was reduced by 50 percent. An FDA advisory panel did not recommend the approval, as the risk related to treatment had not been fully vetted. The center for Clinical Standards and Quality with CMS suggested evidence of possibly harmful side effects, such as brain bleeds, headaches, dizziness, and falls.
Yet Aduhelm secured preliminary coverage on Jan. 11, 2022 for patients enrolled in an approved clinical trial that must be conducted in an outpatient setting. Coverage would also include related services such as positron emission tomography (PET) scans. However, there are parameters regarding the frequency of PET scans and coverage.
Effective Jan. 1, 2022, A HCPCS level II code, JO172, was established for reporting the injection of Aduhelm in 2-mg doses. This is the smallest amount that could be billed in multiple units to accommodate a variety of doses, thus making accuracy in reporting the amount used paramount. Revenue code 636 is used when billing the approved JO172 code.
Again, the patient must be enrolled in an approved clinical trial and meet certain specific criteria to receive the new drug; the patient must have a clinical diagnosis of mild cognitive impairment (MCI) due to Alzheimer’s disease or mild Alzheimer’s disease dementia, and evidence of amyloid pathology consistent with Alzheimer’s disease.
In addition, the patient must not have any neurological or other secondary medical condition that may significantly contribute to cognitive decline. Any medical conditions other than Alzheimer’s disease may increase significant adverse events.
Monoclonal antibodies directed against amyloid for the treatment of Alzheimer’s disease, provided outside of the CMS-approved randomized controlled trials and trials supported by the National Institutes of Health (NIH), are nationally non-covered.
Be aware that the new HCPCS code, J0172, for the drug treatment is effective from Jan. 1, 2022 to March 31, 2022, and is subject to change during a 90-day comment period. Public comment is welcome until March 31, 2022.
Those organizations that treat a population with high prevalence of Alzheimer’s should take note that the clock is ticking; we have less than two months to comment on this drug and its use.
Programming Note: Listen to Susan Gatehouse report this story live today during Talk Ten Tuesdays.
The Centers for Medicare & Medicaid Services (CMS) operates a surveillance platform called the Fraud Prevention System (FPS) that analyzes Medicare claims across the full
EDITOR’S NOTE: Artificial intelligence was utilized for structural refinement and grammatical editing. All analyses, interpretations, and opinions expressed in this article are solely those of
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.
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.
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.
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
