From LOS to CC 44 and the Pepper Report, important news, and updates.
Last week was (thankfully) a boring regulation week. So instead of working to interpret new rules, I was able to do some real work. These last few weeks I have been working on the third edition of my book that I am co-authoring with Stefani Daniels on Hospital Utilization Review. Some of you may know Stefani- she has been working in case management for a very long time. She has helped many hospitals redesign their case management program over the years. To tell you Stefani’s devotion to her work, she first told me in 2017 that she is retiring yet here we are in 2021 collaborating. One of the other reasons I like Stefani is that she agrees with me that length of stay is a terrible metric. Anyways, as I was writing sections, I got to the condition code 44 section. The bulk of the section required no edits since the Medicare condition code 44 process has not changed since 2004 and I was going to move on but then I recalled the RACmonitor article by Dr Juliet Ugarte Hopkins on condition code 44. Reading that article was a huge “aha” moment for me. That article made me realize that condition code 44 was just a number and not a process and we had all been misinterpreting it. So the book now has an in-depth explanation of condition code 44 as it applies non-Medicare payers. Now if you don’t recall reading that article on RACmonitor news, look it up and read it or even better wait until fall and buy a copy of the third edition of the Hospital Guide to Contemporary Utilization Review.
Last week I did a review of a health system’s latest PEPPER. This system had several measures where they were a low outlier. Now being a low outlier is good in that no auditor will waste their time with you, but you must decide if maybe you are too conservative and leaving money on the table. Are you doctors documenting thoroughly or do you need to call Dr. Erica Remer for a chart audit and education? The concern was that this system had an academic medical center and really sick patients. On the call, the physician advisor asked a very interesting question. What if they were doing everything right but many other hospitals were ignoring the rules? How profound. And other data in the PEPPER may support that. The PEPPER data shows that about 20 percent of hospitals in the nation did all their Medicare total knee arthroplasties as inpatient from 2018 to 2020 when it was no longer inpatient only. Do all their patients require a stay over two days or are they all at high risk or were they admitting all as inpatient because no one was auditing?
There are over 5,000 hospitals in the country. There are hundreds of compliance areas where hospitals can stretch the rules or even totally ignore them. And when they do that, the hospitals that are following the rules have their data look like they are underperforming. This goes back to what I said at the beginning- that length of stay is a terrible measure. Likewise, I dislike the term “benchmark rate.” Whose benchmark? Whose data contributed to that benchmark? If the benchmark consists of those hospitals that are flaunting the regulations, is that really the goal you want to attain?
Programming Note: Listen to Dr. Ronald Hirsch conduct his Monday rounds during Monitor Mondays, 10 Eastern, sponsored by R1 RCM.
Healthcare policy has always involved a degree of uncertainty. I have been in healthcare for over 40 years, and early in my career we would
Recent guidance from the Centers for Medicare & Medicaid Services (CMS) on Medicaid State Directed Payments (SDPs) has been widely interpreted as a tightening of
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.
Celebrate Lab Week with MedLearn! Sign up to win one year of our Laboratory All Access Pass! Click here to learn more →
Have a Medicare regulation question you’d love Dr. Hirsch to answer? Now is your chance! CLICK HERE to learn more→
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
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
