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With ongoing scrutiny surrounding Medicare Advantage (MA) Risk Adjustment (RA), the Office of Inspector General (OIG) has issued another significant finding in its May audit report titled: “CMS Potentially Overpaid Medicare Advantage Organizations $462 Million Based on Certain Unsupported Acute Stroke Diagnosis Codes.” Understanding the Medicare Advantage Risk Adjustment Model When discussing Medicare Advantage Risk…

Let’s be honest: nobody gets excited about checklists. No one starts their day looking forward to reviewing controls, validating documentation, or double-checking a process they’ve completed hundreds of times before. To many people, compliance work can feel routine, repetitive, and sometimes even a little boring. But that’s exactly what makes it so valuable. Why Routine…

Present on Admission (POA) indicators do far more than support accurate coding and reimbursement. They play a critical role in reflecting patient severity of illness, risk of mortality, quality outcomes, and ultimately how hospital performance is measured. A POA indicator identifies whether a condition was present at the time of admission or developed during the…

Should respiratory distress syndrome (RDS) and respiratory failure be coded together? Since coding guidelines changed the relationship between these diagnoses from an Excludes 1 note to an Excludes 2 note, many coders have begun reporting both conditions together. However, whether both diagnoses should be coded depends on documentation and clinical circumstances. The coding guidelines now…

Most employees do not leave a company because of one bad day. They leave after months, sometimes years, of feeling invisible. A missed work anniversary. A birthday no one acknowledged. A major accomplishment that earned silence instead of appreciation. Over time, those moments shape how employees feel about where they work and whether their effort…

Healthcare organizations are under sustained pressure from multiple directions: In this environment, organizations that treat Clinical Documentation Integrity (CDI) education as a strategic, data-driven investment are beginning to separate themselves from the pack. For years, many CDI efforts were largely reactive — responding to denials, post-bill audits, or missed reimbursement after the fact. That approach…

Medicare Advantage is also known as the Medicare Part C program. This Medicare program combines traditional Medicare Part A and B into a Part C plan where Medicare beneficiaries have the option of enrolling in and obtaining healthcare from Medicare Advantage Plans (MA Plans) that are owned and operated by private Medicare Advantage Organizations (MAOs)…

Provider documentation often includes phrases that sound clinically meaningful but do not give coders enough support to assign a causal relationship. One common example is “in the setting of.” You may see documentation such as: “Shortness of breath in the setting of CHF.” Or: “Acute kidney injury in the setting of sepsis.” The phrase may suggest…