By Robin Sewell, CDIP, CCS, CIC, CPC, CCDS

How did the phrase “Clinical Validation” get coined when it comes to queries? As Clinical Documentation Integrity (CDI) professionals, we use that term essentially to “invalidate”, not “validate”, a clinical condition when there are insufficient clinical indicators to support it. …But do providers know CDI speak? Do they understand why they are receiving the query? Have we “mis-named” the query type, creating a misnomer? 

How often have you submitted a clinical validation query to rule out a diagnosis only to have the provider “confirm” or “validate” the diagnosis? 

To test out my theory, I “crowd-sourced” several Physician Advisors using a query that was the subject of a denial. The denial was for acute postoperative respiratory insufficiency.  The payer stated that the patient had normal postoperative weaning status post CABG, and as such, acute postoperative respiratory insufficiency was invalid.  

When I read the query, it was obvious to me that the query writer did not think the documented postop respiratory insufficiency was clinically valid, and it appeared their intent was to have it removed, aka “invalidated.”  

The Query In Question

Documentation includes the diagnosis of respiratory insufficiency on the pulmonary consult date xx/xx/25. 

Clinical Indicators: 

xx/10/25 Op note: Operation performed-CABG x2: LIMA to LAD, saphenous vein graft to diagonal, endoscopic harvest of left long saphenous vein… 

Post-Op diagnosis: Multi-vessel CAD 

XX/10/25 Pulmonary Consult: “… Acute respiratory insufficiency, postoperative-on vent postop, tolerating weaning per protocol…” 

XX/11/25 Pulmonary Consult: “… successfully extubated XX/10/25…” 

XX/11/25 Hospitalist Consult: “…Acute respiratory insufficiency, postoperative. Symptoms have resolved. Patient is currently on 3 L nasal cannula. He will be weaned off…” 

Based on the above, please further specify the patient’s respiratory status:

The intention of the query seemed clear to me: The patient was extubated on the same day as the procedure and was tolerating normal weaning.  I agreed with the payer that this was invalid; however, it was not so obvious to the physician.  

The Query Hypothesis

To test my hypothesis that physicians often misunderstand “clinical validation” (and to campaign for reforming the query process), I submitted the query to several physicians to get their opinion. It was an informal poll with these options, while encouraging feedback on their thought process:

1. The query writer wants me to select respiratory insufficiency (regardless of whether it is postop/pulmonary, etc.). 
2. Since the diagnosis is already documented, the query writer does not understand/read the clinical indicators very well.
3. The query writer suspects the diagnosis of acute pulmonary insufficiency is not clinically valid.
4. The query writer wants you to rule out acute or postop pulmonary insufficiency.  
5. Other

Providers who were not involved in CDI functions and who did not participate in clinical validation denials and appeals confirmed the hypothesis. Here were some of the comments by the physicians involved in the experiment:

• “Why would they think it’s not clinically valid? At the minimum the sedation is not allowing the patient to breath on their own.” 
• “I tried to take my knowledge out of the picture, and yes, if you sent this to a physician with minimal insight into coding and CDI, they absolutely would not know what the question is about.”  
• “I think I was asked so often in clinical life about these sorts of issues that maybe I never gave it much thought and just answered the best I could, assuming there was a good reason to be asked.” 
• “I would pick option 2 since the note on xx/10 states that dx. Also, it states that the patient had adequate oxygenation, with no mention of respiratory distress or hypoxia. Instead, it leans towards a quick wean off oxygen.” 
• “…for this case I think it’s straightforward. I don’t think you’d need an MD to validate it.”

These comments were very insightful. They revealed that many physicians do not understand clinical validation, and, as we already know, many do not understand coding guidelines. 

Where To Go From Here

So, what can be done to rectify this knowledge/communication gap? As we patiently await more guidance from AHIMA and ACDIS from an updated Query Practice Brief, can we at least call a spade a spade? What is it we really need from the provider? I vote we label these queries very plainly as “Rule Out Diagnosis.” Then, within the query itself, we clearly explain why.  

Dear Doctor: 

The documentation includes the diagnosis of respiratory insufficiency on the pulmonary consult date xx/xx/25, which has limited clinical evidence supporting it as a valid diagnosis.

Clinical Indicators: 

xx/10/25 Op note: Operation performed-CABG x2: LIMA to LAD, saphenous vein graft to diagonal, endoscopic harvest of left long saphenous vein… 

Post-Op diagnosis: Multi-vessel CAD 

XX/10/25 Pulmonary Consult: “… Acute respiratory insufficiency, postoperative-on vent postop, tolerating weaning per protocol…” 

XX/11/25 Pulmonary Consult: “… successfully extubated XX/10/25…” 

XX/11/25 Hospitalist Consult: “…Acute respiratory insufficiency, postoperative. Symptoms have resolved. Patient is currently on 3 L nasal cannula. He will be weaned off…” 

Based on the above, was the respiratory status normal postoperative weaning from vent, and thus acute respiratory postoperative insufficiency was ruled out: 

_ Yes- Normal postoperative weaning from vent (ruled out) 

_ No- Abnormal postop weaning from vent: Acute respiratory insufficiency, postoperative is clinically valid.

The Takeaway

This isn’t about changing compliance standards. It’s about improving communication clarity.

Because if the provider doesn’t understand the question, we shouldn’t be surprised when we get the wrong answer. 

Maybe it’s time to rethink the term “clinical validation query.” 

Because right now? 

It might be doing the exact opposite of what we intend. 

The post Query IQ: Clinical Validation Queries appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

By Robin Sewell, CDIP, CCS, CIC, CPC, CCDS

In our last Query IQ article, we borrowed a line from The Princess Bride, when the character finally tells Inigo Montoya, “Stop saying that!” after hearing the same phrase repeatedly.

Apparently, we are continuing the Princess Bride theme this month. 

There is another famous line in the movie when Inigo tells Vizzini regarding his constant use of the term “Inconceivable!” 

“You keep using that word. I do not think it means what you think it means.” 

That’s often how CDI specialists and coders feel when a provider documents “sharp debridement.”

In the world of CDI and coding, “sharp” debridement does not necessarily mean that an “excisional” debridement was performed. 

Excisional Debridement 

Inpatient coding guidance has long been clear that describing a debridement as “sharp” or documenting the use of scissors, curettes, or other sharp instruments does not automatically qualify the procedure as “excisional” debridement. The documentation must include an “excisional” tissue removal  to code the root accurately as “excision.”  In the absence of such documentation, the procedure, if coded, is at high risk of denial and DRG downgrade. 

Over the years, CDI specialists and coders have become very good at querying providers to clarify the distinction between excisional and non-excisional debridement.

Identifying the Body Part and Layers Debrided 

However, even when the “excisional” question is resolved, another documentation detail can still create problems: The deepest anatomic layer debrided.

To be fair, documenting the depth of debridement has always been considered best practice. Under ICD-9-CM, however, coders often arrived at the appropriate procedure code through the Alphabetic Index and its sub-terms, where the available codes did not always require the same level of anatomic specificity.

ICD-10-PCS changed that. The coding construct requires coders to select the specific body system and body part directly from the PCS tables, making documentation of the deepest anatomic layer involved critical for accurate code assignment. 

The Payer Denial 

And this is exactly where a recent denial we reviewed came into play. 

In this case, the provider documented that the wound was debrided “down to healthy tissue.”  Well, that doesn’t translate to ICD-10-PCS coding. Therefore, a query for anatomic depth was submitted and answered as “down to fascia”. The payer denied the PCS code, reasoning that since the documentation did not explicitly state that the fascia itself was debrided, the procedure should not be coded at that level, and the DRG should be downgraded. 

Not so fast… 

In ICD-10-PCS, subcutaneous tissue and fascia are grouped under the same body system in the table below. Because these structures share the same body system construct, documentation supporting debridement to either level leads the coder to the same PCS table and body system, meaning the code assignment would not change even if debridement included only subcutaneous tissue. 

The coding is further supported by PCS guideline A10, which states: “And” when used in a code description, means “and/or” except when used to describe a combination of multiple body parts for which values exist for each body part.

Additionally, the phrase “down to” generally implies that the preceding tissue layers were debrided to reach that level. For example, to expose or reach the fascia, subcutaneous tissue would also be debrided, rendering the payer’s rationale for the denied questionable from both clinical and coding perspectives.

While this particular denial may have been a stretch, it highlights an important opportunity for documentation.

Querying for Debridement Procedures in ICD-10-PCS 

When querying providers regarding debridement procedures, it is helpful and compliant to include answer options that clearly identify the deepest anatomic layer debrided, such as: 

• Skin 
• Subcutaneous tissue 
• Fascia
• Muscle
• Bone

Using phrasing such as “down to and including” the specified anatomic layer can eliminate ambiguity and better align the documentation with the ICD-10-PCS coding structure. And of course, don’t forget the other words that still matter: “Excisional.” 

This same principle applies to procedures such as incision and drainage, where the deepest anatomic layer, i.e., the most specific body part, may be distinguished from an anatomic region, thus supplying the most specific code from the PCS coding table. 

Yes, providers may dislike these queries—and frankly, we don’t love sending them either. But when the coding system requires this level of specificity, CDI specialists and coders are simply translating the clinical documentation into the language required by ICD-10-PCS. 

So, the next time a procedure note reads “sharp debridement” and/or “down to” a particular layer, remember the immortal wisdom of The Princess Bride:  “You keep using that word. I do not think it means what you think it means.”

The post Query IQ: “You Keep Saying that Word…” appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Have you seen the scene in The Princess Bride where Inigo Montoya spends his entire life hunting the six-fingered man who killed his father? When he finally confronts him, he repeats, “Hello. My name is Inigo Montoya…” 

Eventually, the six-fingered man snaps back: “Stop saying that!”

This echoes the sentiment CDI and coding professionals sometimes feel when providers repeatedly document phrases such as “elevated troponin” or “demand ischemia” instead of the terms “myocardial injury” or “myocardial infarction” (MI). This clinical and documentation specificity is needed for accurate  coding appropriate reimbursement and accurate tracking of quality measures. 

Why “Elevated Troponin” and “Demand Ischemia” Are Problematic  

The Fourth Universal Definition of Myocardial Infarction clearly differentiates these conditions, which are also amenable to ICD-10 code assignment: 

• Non-ischemic Myocardial injury 
• Type 2 myocardial infarction (T2MI) 
• Type 1 myocardial infarction (AMI) 

When providers document using vague or outdated terminology, they unintentionally create ambiguity – remember urosepsis? Phrases like “elevated troponin” or “demand ischemia” often lead to mischaracterization of the patient’s condition, a lack of specificity and/or unnecessary documentation queries.  

Elevated troponin is an observation and not a diagnosis. Providers may use this term initially until a definitive diagnosis of myocardial injury or infarction is identified. Elevated troponin should never be listed as a final diagnosis.  

Demand ischemia represents the pathophysiologic mechanism for an elevated troponin and should not be used as a standalone diagnosis. If an elevated troponin is due to demand ischemia, the provider should then consider if there are signs/symptoms of ischemia. If yes, the diagnosis should be Type 2 MI. If no, myocardial injury would be most appropriate. Using the term “demand ischemia” alone may result in confusion and a lack of specificity requiring a potential query.  

Recent Documentation Example 

Revisiting the Clinical Criteria… 

According to the Fourth Universal Definition of Myocardial Infarction, Type 2 MI requires: 

1. A rise and/or fall of cardiac troponin with at least one value above the 99th percentile AND 

2. Evidence of myocardial oxygen supply-demand imbalance unrelated to coronary thrombosis, plus at least one of the following: 
   • Symptoms of acute myocardial ischemia
   • New ischemic ECG changes
   • Development of pathological Q waves
   • Imaging evidence of new loss of viable myocardium or new regional wall-motion abnormality consistent with ischemia

By contrast, myocardial injury is defined simply as: 

“Detection of an elevated cardiac troponin value above the 99th percentile upper reference limit.” 

In the above case, the patient had echocardiographic evidence of anteroseptal hypokinesis—a regional wall-motion abnormality consistent with ischemia. Even in the absence of chest pain or ECG changes, this finding supports a diagnosis of Type 2 MI in the setting of elevated troponin levels. However, the query provided options that led to an inappropriate diagnosis of demand ischemia. 

The Ineffective Query

According to the H&P, the patient was noted to have elevated troponin levels up to 1000 in the setting of sepsis. Additional documentation includes: “possible demand ischemia” in a progress note, “myocardial injury” in the discharge summary, and echocardiogram findings of “anteroseptal hypokinesis.” 

Can this clinical evidence and documentation be further clarified as:  

By adding options for “demand ischemia” and “myocardial injury,” the CDI or Coding Professional may  have unintentionally led the provider away from the most clinically accurate diagnosis. 

Query Tip 

Remember, the Query Practice Brief instructs us to add only clinically relevant options and to exclude all clinically irrelevant options. 

Coding Tip 

Type 2 MIs and Myocardial Injury should generally not be coded as principal diagnosis due to the instructional note indicating to “Code first, if applicable, the underlying cause” 

Here’s a practical reference to assist in query construction. 

The Takeaway

When you see “elevated troponin” or “demand ischemia,” pause. Review the record. Look for imaging, ECG changes, hemodynamic stressors, and clinical context. 

Educate your providers on key points:   

• “Elevated troponin” should never be a final diagnosis.  
• The term “demand ischemia” should not be a standalone diagnosis. Demand ischemia should be further specified as a definitive diagnosis of myocardial injury or type 2 myocardial infarction .  
• Use the 4^th Universal Definition of MI when applying the diagnosis of myocardial injury or type 2 MI  

Through education and effective queries, eventually, they will, “Stop documenting that!” 

The post Query IQ: “Stop Saying That!” appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The Program for Evaluating Payment Patterns Electronic Report (PEPPER) was on hiatus for over a year, but it is finally available again to short-term acute care (STACs) hospitals. Versions for other facility types are expected to be released in the coming months.  PEPPER is a comparative report that summarizes paid Medicare Fee-for-Service (FFS) claims by Medicare fiscal year (FY) quarter that may be at-risk for improper payment.  

Medicare Billing Compliance:

General Guidance 

Medicare has a couple of different Medicare FFS compliance tools. The Comprehensive Error Rate Testing (CERT), a program implemented in 1996 to estimate the national Medicare FFS improper payment rate, establishes target areas for all other Medicare FFS audit programs  (e.g., Medicare contractors such as Medicare Administrative Contractors and Recovery auditors). It is the only program in which Medicare contractors may randomly select claims for audit. Audited STAC claims are classified as a hospital outpatient (Part B), Part A (excluding hospital inpatient prospective payment system – IPPS), and Part A (hospital IPPS). CERT findings are published annually.  

To determine the improper payment rate for Medicare Part A in 2025, 18,041 claims were sampled, and 8,750 were reviewed, resulting in an improper payment rate of 3.1% (Table A1). Currently, Medicare Part A has the lowest improper payment rate of all claim types audited by CERT. Medical necessity errors accounted for the largest share of improper Part A payments at $2.9 billion (Table A5). As expected, the improper payment rate is higher for shorter inpatient admissions stays (zero to one day) with a rate of 17.8% of claims billed to Medicare Part A. This is somewhat surprising since the Medicare Two-Midnight Rule has been in use since 2013 with limited modifications since that time.  

Medical necessity denials can have a greater impact on revenue than coding errors. When an inpatient claim is denied payment under Medicare Part A, how quickly the organization corrects the patient’s status determines the extent of the revenue leakage. If patient status is corrected quickly, the hospital may be able to bill observation services in addition to separately billable Medicare Part B services, if an order is placed and at least eight hours of observation care is provided.  

Unfortunately, due to limited utilization review (UR) staffing, antiquated UR workflows, lack of Physician Advisor support and other factors, medical necessity errors usually are not caught until the patient has been discharged, preventing the hospital from the ability to bill observation services.  

Medicare Billing Compliance:

Hospital Specific Guidance 

Where CERT provides general information for all hospitals, PEPPER provides hospital-specific information. The format and structure of PEPPER allow a hospital to easily identify specific MS-DRGs that may be vulnerable to improper payment due to medical necessity errors.   

PEPPER Methodology: 

PEPPER is designed to highlight specific target areas that are vulnerable to medical necessity or coding errors that can contribute to improper Medicare payments.  In this blog, the focus is on medical necessity target areas, but there is overlap between these areas as some are the result of both medical necessity and coding errors. These include: 

• Percutaneous cardiovascular (CV) procedures 
• Knee Replacement
• Syncope
• Digestive System Diagnoses
• Medical Back
• Spinal Fusion
• 3-Day Skilled Nursing Facility (SNF)
• 2-Day Medical MS-DRGs
• 2-Day Surgical MS-DRGs
• 1-Day Medical MS-DRGs
• 1-Day Surgical MS-DRGs

What sets PEPPER apart from other Medicare audit tools is that hospitals are compared against their peers at the state, jurisdiction, and national level. This comparison allows Medicare to identify hospitals that are outliers, defined as those in the top or bottom 20 percentiles within each comparison group. Medicare recommends that hospitals are outliers confirm that their revenue cycle practices are compliant with Medicare billing requirements.  

Compare target reports (Table 2) can be extremely helpful for hospital leadership to understand the relationship between medical necessity denials and hospital revenue. This table includes a column for the sum of payments. In the sample ST-PEPPER 2025 Q3 report available on the PEPPER website, the dummy data reveals the hospital as a high outlier for the target areas of Percutaneous CV procedures and medical back.  

Specifically, the hospital had 23 Medicare Part A claims that generated $349,280 in payments. Because this is a quarterly report when multiplied by four, this provides an estimate of annual dollars at risk within this one target area: $1,397,120. It is unlikely that all these claims will be denied. Still, even if a fraction of them could have a detrimental impact on hospital finances, especially if the hospital has a low or negative operating margin.  

Conclusion 

Far too often, hospital leadership views UR as a cost center and is reluctant to invest in resources to optimize accurate Medicare billing, including the use of external vendors. In a healthcare environment where payer denials are increasing year-over-year, it is not only the payments at risk, but the cost associated with appealing denials that must be considered. American Hospital Association Report found, “administrative costs now account for more than 40% of total expenses hospital incur in delivering care to patients.” Furthermore, they argue, “hospital staff must expend valuable time and resources to overturn inappropriate denials, adding unnecessary cost and burden to the health system.”    

The post Examining Medical Necessity Compliance in Medicare Part A  appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

By Robin Sewell, CCS, CDIP, CPC, CIC, CCDS-O

In Clinical Documentation Integrity (CDI), there is an uncomfortable truth we rarely acknowledge openly: sometimes the right query results in a lower-paying DRG. And that is not just acceptable; it is ethically the right thing to do. Compliant querying means clarifying ambiguous documentation within the health record regardless of the impact on revenue. Especially if querying can prevent future denials.  

We’ve all felt the internal tug-of-war when a query might reduce reimbursement. It’s the moment when Adam Sandler’s famous Waterboy quote creeps into the back of your mind: “What Mama don’t know won’t hurt her.” The line implies the coder or CDI professional can just look the other way—because who can say for certain that they saw the query opportunity and chose not to act? 

However, in the world of compliant CDI practice, this mindset is the textbook definition of a sin of omission. 

Ethical CDI requires balance if we query when it increases reimbursement; we must also query when it can reduce reimbursement as well. Think of it as a compliance win.  

Anything less is selective integrity, and payers will absolutely catch it. And when they do? They’ll downgrade the case for you, on the grounds that a query should have been issued. 

Catheter-associated infections provide a prime example. A catheter-associated UTI with sepsis as a secondary diagnosis often results in a higher-paying DRG. Because of this, CDI specialists commonly query for a potential CAUTI when the clinical indicators support it.  Occasionally, however, the confirmed catheter associated infection results in a downgrade of the DRG. Here is a recent example. 

Case Example: A Perfect Setup for a Sin of Omission 

Patient: 67-year-old male 

Past Medical History: CKD III, type II diabetes, COPD, CAD s/p CABG, neurogenic bladder with chronic suprapubic catheter 

Admitted For: Candidal sepsis due to UTI 

H&P Notes: 

“Fungal UTI, suprapubic catheter changed in the emergency department.” 

The relevant clinical indicators are all present: 

• Chronic suprapubic catheter 

• Fungal UTI on admission 

• Sepsis due to fungal UTI 

• Catheter manipulation/change in ED 

These findings support issuing a query for possible catheter-associated UTI (and associated sepsis).  

And here’s where the discomfort sets in: 

If confirmed by the provider, the case would require sequencing the complication code  as principal diagnosis resulting in a DRG payment decrease of over $800. 

 Here’s how it works: 

The weight difference of -0.1188 equates to ~$825. When hospitals are fighting for every dollar, these changes can add up! It can also negatively impact traditional CDI metrics like Case Mix Index and CC/MCC Capture rates.  

Compliance reigns supreme 

Coding guidelines stipulate that the complication must be sequenced first. We don’t get to ignore this simply because the outcome isn’t financially favorable. 

The query must be sent. Compliance Is Still King. 

The AHIMA Code of Ethics is explicit: 

A health information management professional shall not: (not all-inclusive list) 

• 4.8 Participate in, condone, or be associated with dishonesty, fraud, abuse, or deception. 

• Allowing patterns of optimizing or minimizing documentation/coding to impact payment 

• Miscoding to avoid conflict with others 

• Hiding or ignoring review outcomes 

In other words: 

• Choosing not to query because it reduces reimbursement is manipulation. 

• Silence can be fraud. 

• Avoiding a query to prevent a downgrade is flat-out noncompliant. 

• Our obligation is to accuracy — not revenue. 

Takeaway 

If the clinical indicators support a diagnosis—but the documentation is unclear, inconsistent, or incomplete: 

Send the query.  Even if it lowers reimbursement. 

The real risk is not the loss of $800. The real risk is ethical implications and payer denial.  

Next on Query IQ 

“Keep It Simple, Stupid.” 

Why overly complex queries create unnecessary confusion, and how simplifying your queries can dramatically improve provider response accuracy, denials prevention, and CDI credibility. 

The post Query IQ: Beware of the Sin of Omission appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

When the clinical indicators listed in a query don’t support the response options, it becomes vulnerable to denial as a noncompliant or leading query. 

In this edition of Query IQ, we examine a real example in which sepsis was included as a query option without adequate clinical support, resulting in a denial for “introducing an undocumented diagnosis.” 

What the Guideline Says 

According to the 2022 AHIMA/ACDIS Query Brief: 

Compliant Query Guidelines (Page 6) 

II. Diagnosis answer options that are not already documented in the health record must be supported by clinical indicators sourced from the medical record. These clinical indicators must be included within the query.   

What the Guideline Means 

Payers often misinterpret this guideline to mean that an undocumented diagnosis may never be presented as a query option. However, that is not what the guideline means. The above guideline means that if the documentation has clinical indicators to support a query, the condition may be presented as a query option, even if the actual condition is not yet documented.   

 CDI work is a lot like detective work, with one key difference — you can search for clues, but you can’t plant them at the crime scene.  You can only ask about the diagnosis if the “clues” are already there — evidence such as abnormal diagnostics, or treatment without an associated diagnosis. If offering a diagnosis as a query answer option without enough clinical support, you’re not solving the case — you’re framing it.   

 Here’s an example we found… 

The Quirky Query  

Based on documentation in the medical record, this patient is being treated for right lower extremity cellulitis. This patient is status post liver transplant on immunosuppressive therapy. 

The following are also documented in the medical record: 

• Platelets = 88 on xx/xx/xx 

Based on your medical judgment, can you further clarify the cause of these findings such as: 

• Sepsis 

• A localized infection only (cellulitis, right lower extremity) 

• Another condition (please specify) 

What went wrong?  

You may have spotted it right away! Sepsis criteria were weak at best — and the patient had clear underlying liver disease, including post-liver transplantation. Thrombocytopenia in this setting is more likely related to baseline pathology. Listing sepsis as a response option introduced a new diagnosis without support, making the query noncompliant. 

The Payer Perspective 

Most payers rely on Sepsis-3 criteria, which include: 

• Infection 

• A SOFA score increase ≥2 (organ dysfunction directly attributable to infection) 

Many payers take it even further, applying interpretations not directly found in sepsis literature. For instance, they may require that organ dysfunction be “remote” from the site of infection. In other words, they will not apply SOFA criteria if organ dysfunction could otherwise be attributable to a chronic condition. For example, they will routinely discount: 

• P/F ratio abnormalities if sepsis is due to pneumonia 

• Elevated creatinine if the patient has CKD 

• Elevated bilirubin if the patient has chronic liver disease 

• And yes — thrombocytopenia in a post-transplant liver recipient 

Step Away from the Query 

 In this case, the query-based denial was legit. There was no compliant way to introduce sepsis as a diagnosis option. The clinical indicators — including the patient’s immunosuppressed state and platelet count of 88 — may have triggered a second look by the CDI, but without documentation linking the thrombocytopenia to infection, a query for sepsis would be speculative at best. In fact, this may be viewed as a fishing expedition! 

Final Takeaway 

To compliantly introduce a diagnosis in a query, the indicators must clearly support it. The organ dysfunction must be attributed AT LEAST IN PART to infection to pass scrutiny and to be compliant.  

The post Query IQ: When Clinical Indicators Don’t Match the Diagnosis  appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Thanks to the dietitian’s note, severe malnutrition was documented and reflected in the discharge summary. At first glance, it looked like it was buttoned up. The physician electronically signed it. The documentation is there. So why do we recommend a query? 

Because sometimes, copy-paste isn’t documentation – it’s decoration. 

In this edition of Query IQ, we’re tackling the question: Is it enough to carry a dietician’s note into the discharge summary to support coding for severe malnutrition? Spoiler: not usually. 

The Case That Sparked the Question 

During a recent DRG prebill review, we found a case where a dietician’s note diagnosing severe malnutrition (E43) was pulled directly into the discharge summary and electronically signed by the attending physician. Based on that, the diagnosis was coded. 

From a distance, this might look like valid documentation. But when you zoom in, there’s no independent physician assessment, just a pasted note. There was no discussion of clinical significance, no mention of treatment or evaluation, and no confirmation that the provider reviewed or agreed with the dietician’s findings. While dietary consultation may be considered a form of evaluation, without specific documentation by the provider, many payers may argue dietary evaluation is routine in the hospital setting.  

Think of It Like an Abnormal Finding 

Let’s draw a parallel. When a patient undergoes a chest X-ray or CT on admission, the radiologist might report something abnormal – an infiltrate, for example. The provider often repeats that finding in their note: 

“X-ray shows left lower lobe infiltrate and possible pneumonia.” 

But per ICD-10-CM Official Guidelines Section III.B, that’s not enough. It states: 

“Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. Suppose the findings are outside the normal range and the provider has ordered other tests to evaluate the condition or prescribed treatment. In that case, it is appropriate to ask the provider whether the abnormal finding should be added.” 

In other words, it’s not reportable unless the provider comments on what the abnormality means – by diagnosing, treating, or ordering further evaluation. Just citing the test result isn’t enough. 

The same concept applies to dietitian documentation, who isn’t even an independent licensed professional authorized to make reportable diagnoses. 

 Coding Clinic Contains a Similar Scenario 

Coding Clinic for ICD-10-CM/PCS, First Quarter 2020: Page 4 touches on a similar issue: a dietician documents severe malnutrition, and the physician later electronically signs the note. The question was whether the provider’s e-signature alone makes it appropriate to assign the malnutrition code. 

Coding Clinic declined to take a firm stance, stating that this falls under facility-level policy decisions. But here’s the reality: just because Coding Clinic defers to internal policy doesn’t mean it will hold up under payer review. In today’s environment, relying solely on an e-signature without clear physician attribution of clinical significance is a gamble that often results in denial. 

A Better Approach to Querying 

If your providers are electronically signing nutrition notes without incorporating the diagnosis of malnutrition into their own documentation, it’s worth stepping back to address the root cause. Consider a multi-pronged strategy: 

• Educate physicians on the coding implications and denial risk when malnutrition isn’t directly acknowledged in their own words. 

• Collaborate with physician leadership to develop a consistent, system-wide documentation standard for referencing dietician findings. The answer could be as simple as provider documentation “Agree with dietician assessment”. 

• Query selectively, when the documentation leaves too much ambiguity — but don’t let queries become the default fix. 

Sending the same query over and over isn’t a sustainable solution. Instead, use these moments to create clarity and consistency — not just for compliance, but for defensibility. 

Final Takeaway 

The physician’s signature doesn’t turn a dietitian’s note into a diagnosis. 

Treat it like an abnormal test result requiring physician interpretation to be coded. 

Empower physicians through education and collaboration to reinforce documentation accuracy and compliance.

Ready to strengthen your query practice? 

Connect with Brundage Group for expert guidance on structuring compliant, clinically sound queries that protect revenue and reduce denials. 

The post Query IQ: Copy, Paste, Denied — When Dietician Notes Aren’t Enough  appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

In our last issue of Query IQ, we talked about approaching queries with a scientific mindset: Start with a hypothesis, build your case with solid clinical evidence, and structure your query accordingly. Sounds simple, right? Well… not exactly. 

Crafting a query that’s clear, compliant, and clinically meaningful is both an art and a science. I’ve got the science part down — hypothesizing and digging through data is second nature. But when it comes to the art of structuring a truly compliant, well-balanced query, I often turn to my colleague Cheryl Ericson, Director of UM and CDI at Brundage Group. 

In this edition of Query IQ, Cheryl and I discuss how to craft a clean, compliant, and non-leading query in a real-world scenario where I hesitated to recommend a query for fear it could appear leading. 

 The Scenario: When the Clues Are There, but the Diagnosis Isn’t 

A patient presented without chest pain but had a notable rise in troponin values, peaking at over 1000. Imaging showed anteroseptal hypokinesis on echo. The clinical picture appeared to meet criteria for a Type 2 NSTEMI, but instead the provider documented on the Discharge Summary: “Elevated troponin… suspected to be nonischemic myocardial injury related to sepsis… further cardiac workup deferred to outpatient.” 
 
From a coding perspective, this is a self-inflicted wound! The criteria for Type 2 NSTEMI were met, but the diagnosis was documented as something else; a completely different ICD-10 code! 

Clinical Criteria for Type 2 NSTEMI: 

According to the Fourth Universal Definition of Myocardial Infarction, Type 2 MI requires: 

Plus at least one of the following: 

In this case, the troponin trend and anteroseptal hypokinesis fulfill the criteria for Type 2 NSTEMI. But how do I pose that question when the provider has already documented non-ischemic myocardial injury-on the Discharge Summary? 

Putting on my payer hat for a moment, I can already hear the argument: “Why ask the question? The provider already documented something else.” Call it a little PTSD from all the query-related denials — but it’s exactly this kind of scenario that makes compliant query structure so important. 

Why a Query Is Appropriate in this Scenario 

In this scenario we could apply the inpatient coding guideline regarding uncertain diagnoses,  

If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. 

Or we could query the provider to see if he/she is comfortable making a definitive diagnosis. According to the Guidelines for Achieving a Compliant Query Practice (2022 Update), ambiguous documentation, defined as “documentation that fails to reflect the provider’s intent, impacts the clinical scenario (e.g., diagnoses, complications, quality of care issues), the accuracy of code assignment, and/or the ability to assign a code,” is a general query convention. In this case, we are not sure the current documentation accurately reflects the clinical scenario; therefore, querying is appropriate.  

A query is also supported by coding guidelines because the provider documented “elevated troponin” which is an abnormal finding. In this example, we know additional testing was ordered, an ECHO, which found anteroseptal hypokinesis. The Abnormal Finding guideline states, “If the findings are outside the normal range and the provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.” The discharge documentation does not appear to fully address this significant abnormal finding; therefore, a query is appropriate.  

Clinically, there is conflicting documentation in the health record. It is not uncommon for a diagnosis to be validated with additional investigation, but in this example, the documentation addressing the high troponin levels was uncertain. Additionally, providers documented the possibility of both “myocardial injury” and “nonischemic myocardial injury” injury. The code set assumes “myocardial injury” to be the same as “nonischemic myocardial injury” because “nonischemic” is an unnecessary modifier but clinically, we cannot assume the intent of the provider. The American Journal of Medicine (August 2022) states, “Diagnosis and therapy of type 1 MI are well understood and usually present no problem to the physician.  The clinical scenarios leading to type 2 MI and non-ischemic myocardial injury are, however, often fraught with greater degrees of uncertainty.” This report follows a 2019 article in JAMA Cardiology that found, “Patients with nonischemic myocardial injury frequently receive incorrect diagnoses and are billed as having T2MI.” It is appropriate to query when there is conflicting documentation in the health record. This is where having access to a physician advisor is helpful because they can assist with determining if the clinical scenario is accurately represented by the current documentation. Remember, we must not only rely on coding conventions and guidelines, but also continuity of the clinical scenario.  

The Query 

Because querying is somewhat subjective, query professionals and payers may disagree what is necessary for a query to be compliant with industry guidance. Payers may try to challenge a simple, concise query but being clear and concise is a general query guideline.  

Most providers prefer when the query begins with the question because not all providers need to review the included clinical indicators depending on their familiarity with the patient. It is also not necessary to ask the provider to use their independent judgment, the provider is legally responsible for establishing diagnoses. Just like health information professionals, medical professionals must abide by a code of ethics; however, providers must also be weary of liability so there is even more incentive for a provider to accurately diagnosis and treat a patient.  

Based on the clinical indicators presented below, can the conflicting documentation of in the health record be further clarified as   
( ) Type 2 NSTEMI  
( ) Non-ischemic myocardial injury  
( ) Other (please specify): _________________

Clinical Indicators from the Medical Record

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You can spot a templated query a mile away: Overly long, loaded with generic verbiage, or padded with so much irrelevant detail that the actual question gets lost in translation. It’s like going on a scavenger hunt — without a map. 

At the other end of the spectrum is the dropdown-style template with a simple option to “add” a diagnosis code— a format that carries a high risk of denial. 

In this edition of Query IQ, we’re exploring how to make templates work for you, not against you, and how a thoughtful, concise approach can elevate compliance and clarity and invite fewer query-based denials. 

Customize or Compromise 

Templates are meant to be edited and customized, yet far too often, we see them left unaltered. For example, only a few clinical indicator prompts are filled with copy-and-paste data or irrelevant query options   needlessly take up space on the query form. The ACDIS/AHIMA query practice brief states query options need to be supported by the clinical evidence.  More often than not, pneumonia templates list every possible pneumonia etiology under the sun without clear insight into why the author is posing the question. 

The dropdown-style template with a simple option to “add” a diagnosis code must be carefully edited and tailored to the clinical scenario. Without proper customization, these queries are a compliance risk and may compromise defensibility if the payer denies them. 

Tip: If you’re cutting and pasting or selecting dropdown options more than you are clinically clarifying, it’s time to revise your strategy. 

Queries Should Be Clinically Grounded and Conscise

Think like a scientist. Hassan Rao, MD, Associate Chief Medical Officer and VP, DRG Integrity Service Line at Brundage Group, states that every query you write should reflect a clear hypothesis: Was sepsis present on admission? Could encephalopathy be further clarified as metabolic? Can the labs and clinical context be further clarified as AKI? Is fluid overload an indicator of an acute exacerbation of systolic heart failure? Having clear intent while writing the query allows you to focus on the appropriate clinical indicators and options to provide. The best and easiest queries for providers to answer are the ones that are succinct and concise. While it may not be possible for every clinical scenario, being able to craft a concise query is the mark of a skilled CDI/coder.

Be genuinely curious! 

The structure of your query should match its purpose: 

• If you’re trying to validate something (e.g., sepsis), clearly organize your indicators to reflect the hypothesis and why you’re questioning it. 

• If you’re trying to clarify an omitted diagnosis, be sure the clinical indicators are relevant to the query options and the connection to your hypothesis is clear. Without that focused intent, queries can feel like fishing expeditions — and that opens the door to accusations of authoring a leading query and potential denials. 

Template Truth: One Size Doesn’t Fit All 

You need different templates or structures depending on the scenario: 

• Clinical validation – Keep it tight, focused, and explicitly present supporting and conflicting evidence for the diagnosis in question. 

• Missed diagnosis – Lay out the timeline and clinical indicators and ask a multiple-choice question that reflects your clinical reasoning. (Don’t forget to include the option of Other!) 

Templates are tools — but they should be used with purpose and precision, not as fill-in-the-blank forms where ICD-10 codes are dropped in willy-nilly. 

Compliance is Still King 

It is an art and a science to strike a balance that is neither leading nor vague. But it’s much easier for a provider to understand your intent if you frame the clinical picture clearly: 

“Despite normal vitals and no documented organ dysfunction, sepsis was documented. Please clarify…” 

That’s not leading — that’s thoughtful. And that’s the difference between a query that sparks a response and one that gets ignored (or worse, denied). 

5 Best Practices for Templated Queries 

1. Edit the Template – Always customize. If something doesn’t apply, remove it. If something is missing, add it.  

2. Lead with Purpose – What are you hypothesizing? Write with that intent in mind. 

3. Be Concise – More words ≠ more clarity. Use bullets, short sentences, and clean formatting. 

4. Frame the Hypothesis – Demonstrate clinical reasoning that aligns with the query’s intent and makes sense with the options provided. 

5. Match Structure to Purpose – The format of your query should reflect what you’re trying to accomplish, whether validating a diagnosis or clarifying documentation. 

The post Query IQ: Are Your Query Templates Friend or Foe? appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

When Payers Demand More Than What’s Required

A query walks into a hospital, and the payer says, “Sorry, we don’t serve your kind here without source documentation citations.”

It’s a joke — but lately, most query-related denials are.

We recently received a denial claiming that an otherwise compliant query was invalid because it didn’t specify the exact location of clinical indicators in the record. And just in case that argument didn’t hold up, the payer added a second layer — stating the condition couldn’t be reported because it wasn’t treated.

The payer stated:

“Upon review of the medical record and the available physician query form, there was no citation or location of clinical indicators, and it was not compliant per AHIMA query guideline practice. The query did not have treatment for non-ischemic myocardial injury.” This reflects a growing trend: Misapplying industry guidance to justify denials. For context, this is what The American Health Information Management Association – Association of Clinical Documentation Integrity Specialists (AHIMA-ACDIS) Practice Brief states regarding citation location of clinical indicators: “Clinical indicators should include a citation of the location found within the health record.”

Denial Debrief: Myocardial Injury Clarification

Here’s the query in question:

This query is being sent for clarification of the following documentation in the medical record:

• ED documentation: The patient presented for evaluation of loss of peripheral vision and headache. Admitted for CVA.
• Cardiology note: Denies chest pain, shortness of breath, dizziness, lightheadedness, syncope.
• Troponin trend: 21 → 40 → 182 → 401
• EKG: Sinus rhythm with nonspecific abnormalities

An ischemic workup was deferred in the acute CVA setting with no ischemic symptoms. Type 2 MI suspected.

Based on your medical judgment, please clarify which, if any, of the following diagnoses apply:

• (X) Non-ischemic Myocardial Injury
• (  ) Type 2 MI due to  _______
• (  ) Other: __________________

The physician selected Non-ischemic Myocardial Injury in response.

The diagnosis was denied despite referencing the ED and cardiology documentation, the source of the clinical indicators, and outlining clear clinical indicators.

Response: Clarification Is the Purpose

This query is both appropriate and compliant. It was issued to clarify whether a suspected diagnosis—Type 2 MI—was ruled in, ruled out, or should be otherwise specified. That intent is fully supported by the 2022 AHIMA/ACDIS Practice Brief, which states that compliant queries may be used:

• To establish clinically supported acuity or specificity of a documented diagnosis to avoid reporting a default or unspecified code
• To determine if a diagnosis is ruled in or ruled out

The denial incorrectly claimed the absence of treatment invalidated the query. Official Coding Guidelines do not require treatment as a required element for capturing a secondary diagnosis and the Practice Brief does not require treatment as a clinical indicator. Valid clinical indicators may also include (among others):

• Evaluation
• Monitoring
• Diagnostics
• Clinical Context

In this case, the troponin trend combined with a lack of ischemic symptoms, and clear documentation of suspected Type 2 MI provided a defensible, clinically sound rationale for clarification.

Additionally, the query clearly sourced the “cardiology note” rendering the payer’s interpretation of the Query Brief invalid.

Final Thought

This denial reflects a broader issue: payers are shifting focus from the clinical appropriateness of a query to technical aspects of query formatting. Industry standards remain unchanged; keep your queries clear, specific, and rooted in the record to withstand scrutiny.

The post Query IQ: Clarifying Clinical Indicators appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

If your blood pressure spikes every time you read “denied due to query noncompliance,” you’re not alone and certainly not overreacting. Over the last few months, we’ve seen an uptick in query-related denials. 

Sure, in some instances, queries could be of better quality (we’ve all seen that second query sent when the first response wasn’t what someone had hoped for), but let’s be honest: Most of these denials target compliant, well-documented, and clinically sound queries. 

So, what’s going on? 

A recent inclusion in their arsenal is the Guidelines for Achieving a Compliant Query Practice from the American Health Information Management (AHIMA)/Association of Clinical Documentation Integrity Specialists (ACDIS) where some payers are twisting the contents beyond recognition, as if it were written in a yoga manual instead of a legitimate medical record. 

Let’s be clear: this is not a denial based on provider documentation per se.

It’s not a clinical concern for the patient.

It’s a revenue protection strategy by the payer.

Misusing the Query Brief to deny legitimate, clinical diagnoses identified through the query process is not only deceptive but may also be detrimental to hospital reimbursement.

Introducing Query IQ: Your Defense Against Denials

Welcome to Query IQ, an educational series designed to provide you with the tools, real-world query examples, and strategic best practices to defend compliant queries against denial games.

Payers should not rewrite the rules whenever a Major Complication or Comorbidity (MCC) tantalizes them.

Denial Debrief: The “Other” Excuse

Let’s walk through a recent denial example that’s almost too absurd to believe.

The Clinical Scenario

Operation Date: xx-xx-2025

Pre-op Diagnosis: Incarcerated epigastric hernia

Post-op Diagnosis: Strangulated epigastric hernia containing small bowel

Procedures:

• Diagnostic laparoscopy
• Open hernia repair
• Small bowel resection

Pathology Report Highlights:

• Small intestine: Segmental resection with ischemic enteritis
• Hernia sac: Confirmed incarceration

The Query Sent to the Provider

Based on the above, please provide an appropriate diagnosis that supports the clinical indicators, including evaluation, monitoring, and/or treatment:

• Acute ischemic bowel
• Chronic ischemic bowel
• Acute on chronic ischemic bowel

Physician Response: Acute ischemic bowel

Payer Denial: “No option for ‘Other’ was provided.”

Brundage Group Response: Including an “Other” or similar terminology is best practice, but let’s not kid ourselves: This was a clinically specific, well-structured query. The physician was asked to clarify the acuity of the ischemic bowel: Acute or Chronic, thus averting a default or unspecified code.

And guess what?

That’s precisely what the 2022 AHIMA Query Brief supports:

II. When to Query:

“To establish clinically supported acuity or specificity of a documented diagnosis to avoid reporting a default or unspecified code.”

That’s what we did. We avoided the non-specific K55.9 (Unspecified ischemic bowel) in favor of an accurate, more clinically meaningful code.

The Official Coding Guidelines Also Say…

• Use unspecified codes only when more specific documentation isn’t available
• Code to the highest level of specificity — if the info is there, use it

Query IQ Tip: Build Bulletproof Queries

Even when it feels redundant or out of place, always include “Other” or similar terminology in multiple-choice queries. This will not change the clinical truth but will remove a weak excuse for denial.

Think of “Other” as a seatbelt: You can leave it off, but we don’t recommend it, and it is the law!

Coming Up Next in Query IQ

Stay tuned for the next edition, where we’ll tackle the denial that claims: “You didn’t cite clinical indicators correctly.” (Spoiler: we did).

The post Query IQ: The “Other” Denial-When Payers Rewrite the Rules appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

By Hassan Rao, MD, CCS, CPC

As a Physician Advisor, I’ve seen firsthand how critical a robust Diagnosis-Related Group (DRG) validation process is to hospitals’ financial and operational health. In an environment where accurate documentation and coding directly impacts revenue, compliance, and the quality of patient care, establishing a well-defined process for DRG validation is not just an option—it’s essential.

Why DRG Validation Matters to Physicians

From my experience, DRG validation is about more than just billing. Ultimately, it’s about ensuring the patient’s clinical story is adequately reflected in the documentation and codes. This alignment is critical for several reasons:

• Accurate Reimbursement: As physicians, we know that the complexity of our patient’s conditions is only sometimes fully captured in the initial coding. Additionally, hospitals can lose substantial revenue when documentation doesn’t reflect the actual severity of illness.
• Reducing Denials: Denied claims place a significant administrative burden on hospitals and clinicians. Validating DRGs ensures that the documented and coded are clinically valid and aligned with coding guidelines, reducing the risk of costly denials.
• Compliance and Audit Readiness: Physicians are held to high standards of care and documentation. A robust DRG validation process helps ensure compliance with coding guidelines, reducing the likelihood of audits and penalties related to high-risk DRGs.
• Quality Measure Performance: Many hospital quality measures such as those within the Center for Medicare and Medicaid Services (CMS) value-based purchasing measures are based entirely on the coded record rather than clinical outcomes. However, this discordance can result in low quality measure performance if the coded record is not an accurate and complete picture of the patient’s conditions and course. 

The Power of Collaboration

The most successful DRG validation efforts involve collaboration between multiple teams. CDI specialists, coding professionals, and Physician Advisors each play a vital role:

• CDI Specialists: With their clinical expertise, CDI teams help ensure documentation accuracy and clinical validity. They often identify documentation gaps that can be corrected before coding occurs.
• Coding Experts: Coding professionals ensure the codes applied are accurate and in line with current regulations. They bridge the gap between clinical documentation and the billing process, ensuring that the hospital is reimbursed appropriately. 
• Physician Advisors: Provide additional clinical insight, and a unique perspective needed to ensure that the DRGs accurately reflect the patient’s clinical condition. Our involvement often helps resolve clinical documentation discrepancies, improve queries, and provide necessary education to achieve more accurate coding and improved compliance.

CDIs and coders review cases concurrently, but an additional second-level review may be valuable for certain DRGs. Analogous to clinical workflows, redundancy through collaborative efforts—such as two nurses verifying a high-risk medication dose—helps reduce clinical errors. Although multiple checks within CDI and coding are not always feasible, applying this concept can reduce revenue leakage and improve compliance by ensuring that the coding and documentation in certain cases are accurately reflected in the claim codes

Our Results at Brundage Group

At Brundage Group, I’ve been proud to be a part of a team of CDI, coding professionals and Physician Advisors that have delivered exceptional results through our DRG Validation Reviews:

Over 700% ROI

Our clients consistently see a significant return on investment.

Average Medical DRG Impact of $2K

This is the average financial uplift we identify per medical case.

Average Surgical DRG Impact of $4.5K

For surgical DRGs, the impact is even more significant.

Improved Compliance

We’ve helped countless hospitals identify high audit-risk DRGs, ensuring they are better prepared for regulatory scrutiny.

Denial Reduction

Through our collaborative efforts, hospitals have seen a significant reduction in denial rates, which ultimately frees up resources and improves cash flow.

Education and Sustainable Solutions

Education is at the core of our philosophy at Brundage Group. We include education on each case deliverable to help improve coding, CDI or provider documentation for a sustainable, long-term solution.

Taking Action as a Physician Advisor

For Physician Advisors like me, being actively involved in DRG validation has allowed me to bridge the gap between clinical care and the administrative side of healthcare. Moreover, it’s not just about ensuring the hospital gets paid; it’s about ensuring that the patient’s story is accurately documented and that we, as clinicians, are correctly credited for the complexity of the care we deliver. 

If you’re a Physician Advisor or hospital leader, I strongly urge you to participate actively in DRG validation. The impact goes beyond finances—it ensures compliance, reduces denials, and improves the overall quality of care.

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Explore Dr. Hassan Rao’s transformative journey from hospitalist to certified coder, as an Executive Physician Advisor at Brundage Group. In “Physician Advisor Turned Coder: How I Learned to Tackle the Practical Challenges of Clinical Documentation,” Dr. Rao shares his journey from practicing hospitalist to delving into the complexities of clinical documentation and coding. Discover how he collaborates with Robin Sewell, a veteran coder and Clinical Coding Analyst at Brundage Group, to bridge the physician-coding gap and leads the physician-led DRG validation service line.

Hassan Rao, MD, CCS, CPC, possesses extensive expertise in clinical documentation, coding, quality, and utilization management. Leading the DRG validation service line, Dr. Rao advises clients in coding charts with high fidelity to ensure compliance, minimize denials, and maximize earned revenue. Additionally, Dr. Rao provides education on clinical and complex coding topics to providers, CDIs and coders.

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