DRG Downgrades by Commercial Payers: Documentation Defense Tactics

Published: Tue, 07/08/25

Updated: Tue, 07/08/25

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DRG Downgrades by Commercial Payers: Documentation Defense Tactics

In the current climate of cost containment, commercial payers are increasingly downgrading MS-DRGs after claims are submitted, not disputing the need for inpatient care, but questioning the clinical support for CCs (complications or comorbidities) and MCCs (major complications or comorbidities). These downgrades reduce reimbursement, often occur...

The Devil’s in the Diagnosis Details

I think it is important to challenge one portion of an article that was widely distributed two weeks ago. The article included a statement that, while accurately characterizing the way that Medicare Administrative Contractors (MACs) conduct audits, is still demonstrably incorrect. The article asserts that “the old auditor’s adage for incident-to services remains...

Health info managers launch clinical coding AI adoption guide

An association of health information managers, clinical coders, and clinical documentation specialists in Australia has released a guideline for adopting clinical coding AI solutions. The guideline developed by the Health Information Management Association of Australia (HIMAA) emphasizes a principle-based approach to taking up AI technologies to generate...

How Can Rural Healthcare Organizations Benefit From AI?

Across the industry, health systems are laying the foundation for artificial intelligence success, ensuring they have the infrastructure, governance and technical expertise to make the most of the technology. Organizations that get this right are well positioned to increase efficiency, enhance care quality and take advantage of predictive models.

Coding Alert: Welcome to Summer!

Our sunburn codes are found at L55. We only have four straightforward code options here: L55.0 for Sunburn of first degree, L55.1, Sunburn of second degree, L55.2, Sunburn of third degree, and L55.9 Sunburn, unspecified. Cleveland Clinic notes that most first- and second-degree sunburns can be self-treated at home (I know I have on more than one...

The AI Advantage: Navigating the 2026 Medicare Advantage Rate Bump

The Centers for Medicare & Medicaid Services (CMS) recently released its 2026 Medicare Advantage (MA) Rate Announcement (Opens in a new window), projecting a 5.06% average increase in payments to MA plans — a significant jump from 2025. This signals growing confidence in the Medicare Advantage model. But with this comes greater...

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