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

Every so often a query crosses our desk that isn’t leading, isn’t vague, and isn’t technically non-compliant; it’s just too much. Too many findings crammed into one question, redundant phrasing irrelevant to the query purpose, and answer options that muddy rather than clarify the actual question.

We call this query bloat, and it’s just as damaging to a compliant, clinically meaningful query as leading language is.

The Scenario: Everything and  the Kitchen Sink 

A recent query asked the provider to clarify “any clinical significance” for a bundled list of risk factors, clinical indicators, and treatments with options ranging from “clinically insignificant” to “represents metabolic encephalopathy” to “represents baseline dementia only.” 

The patient: an elderly woman with dementia, admitted for weakness and a UTI, with mental status that fluctuated throughout the stay against a baseline already documented as “typically disoriented.” 

The Original Query 

Clarification of Clinical or Diagnostic Findings

Dear Dr.,

Based on your medical judgment, can you further clarify any clinical significance for the risk factors, clinical indicators, and treatments below:

☐ Risk factors, clinical indicators, and treatments below are clinically insignificant

☐ Risk factors, clinical indicators, and treatments below represent metabolic encephalopathy

☐ Risk factors, clinical indicators, and treatments below represent patient baseline confusion and is dementia only

☐ Other (please specify): ___________

☒ Clinically unable to determine / Unknown

Female patient, 90+, with pertinent history of dementia, atrial fibrillation, stated chronic renal failure, HTN, IDDM, depression, HLD, and GERD, brought in from home. Patient is admitted for generalized weakness and UTI.

Clinical Indicators: 

ED Note: Independently ambulatory at baseline and is typically disoriented at baseline according to her three family members present.

— Arrival to the ED she was unable to rise and walk or transfer on her own.

— PSYCHIATRIC: Normal mood and affect. Calm, cooperative. She is not oriented to the year or month which is baseline per the family.

Hosp Day 1: Remains mildly confused but is able to state she is at the hospital and believes it is a different month. She was awake when checked overnight and reported sleepiness but has not slept yet.

Hosp Day 2: She does have a history of dementia; however, they feel it was worsening.

— NEUROLOGIC: Alert and oriented x 3, GCS 15, normal mentation and speech. Moves all extremities x 4 without motor or sensory deficit.

Hosp Day 3: She was found to have a urinary tract infection and was started on Rocephin and admitted here. Her mental status has cleared, but she still continues to be quite weak. She could not participate in therapy yesterday but did participate somewhat this morning.

Treatment: 

Rocephin 1 g, 100 mL/hr, IV Piggyback, Daily 

What Went Wrong 

Asking whether a list of risk factors and treatments “represents” a diagnosis is like asking whether a grocery list “represents” dinner. The question remains: what is being cooked?

The Kitchen Sink: Per the Query Practice Brief, risk factors and treatments aren’t separate from clinical indicators. They are clinical indicators. Throwing them together amid the clinical question blurred and bloated the intent of the query. In fact, there is no reason to include risk factors as these are general findings that can point to a variety of conditions and doesn’t necessarily mean the condition is present. The query should include only relevant clinical indicators that support a vague, incomplete, or missing diagnosis.

The False Choice: “Clinically insignificant,” asks whether something matters at all. If the provider selected that option, then how would they reconcile it with an actual diagnosis? How does that selection bring clarity to the health record and support accurate coding?

The Missed Boat: The golden opportunity to ask one definable question: What is the significance (if any) of acute confusion in a patient with an infection and underlying dementia?

A Tighter Version of the Same Query 

Dear Dr,

Please clarify the etiology of the patient’s mental status changes during this admission:

☐ Metabolic encephalopathy (e.g., related to infection)

☐ Baseline dementia, no acute change

☐ Other (please specify): ___________

☐ Clinically unable to determine

Clinical Indicators:

ED Note: … typically disoriented at baseline according to her three family members present…. PSYCHIATRIC: … She is not oriented to the year or month which is baseline per the family.

Hosp Day 1: Remains mildly confused but can state she is at the hospital and believes it is a different month…

Hosp Day 2: She does have a history of dementia; however, they feel it was worsened… NEUROLOGIC: Alert and oriented x 3, GCS 15, normal mentation and speech.

Hosp Day 3: She was found to have a urinary tract infection and was started on Rocephin and admitted here. Her mental status has cleared…

Same clinical scenario, same underlying uncertainty but now the provider is being asked one identifiable question supported by the indicators that actually bear on it, with options that are genuine, mutually exclusive alternatives.

Query IQ Tip 

Before a query goes out, ask: could I state, in one sentence, the single clinical question this is asking?  If the answer requires an “and,” or the options require the provider to compare apples to oranges, it’s not a sharp query — it’s a bloated one. 

The Takeaway 

This is the discipline Brundage Group builds into every revenue integrity review. Feedback helps your CDI and Coding teams grow their skills and better engage providers through concise, focused queries that matter. If your queries are getting flagged, going unanswered, or just not landing with providers, that’s revenue sitting exposed. Let’s talk about what a sharper approach looks like for your team.

The post Query IQ: When More Isn’t Better, The Trouble with Query Bloat appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Then someone checks the net revenue. It’s up, by a lot.

What’s Actually Happening

Borderline two-midnight patients move from outpatient observation services to inpatient status when clinically appropriate and medically necessary. These low-weight Medicare Severity Diagnosis-Related Groups (MS-DRGs) cases are compliant, but they sit at the lower end of the acuity range. You’re adding volume to the inpatient population with cases that are legitimately appropriate under the Medicare Two-Midnight Rule but have lower severity (e.g., no complications/comorbidities or major complication/comorbidities) compared to the rest of the inpatient population. This one shift explains everything below.

Why CMI Falls

CMI is the average MS-DRG relative weight across inpatient discharges over a specific period. Adding lower-weight cases lowers the average. Coding and documentation didn’t get worse; the denominator expanded to include a healthier patient population.

The tell: CMI falling while inpatient volume and overall revenue rise. In contrast, a falling CMI while inpatient volume holds flat, and revenue per case signals decay, is a real problem. A falling CMI must be investigated rather than assumed to be a problem within the revenue cycle.

Why AR Days Climb

Inpatient claims are paid more slowly than observation claims. Higher dollar amounts and complex coding scenarios trigger more scrutiny from payers. Denied claims sit in the receivables aging while they’re being worked. AR days climb as a direct result of the same underlying shift; a higher inpatient population ratio results in more inpatient claims being adjudicated.

A better way to track AR days is to stop looking at one blended AR number. Track inpatient and observation AR days as separate cohorts. If each cohort’s aging is stable and the blended number moved only because the patient status mix moved, that is an artifact of the UM strategy, not a receivables problem.

Why Denials Rise

More inpatient claims mean more claims exposed to inpatient medical necessity review, especially as payer mix shifts towards Medicare Advantage. Adding three hundred inpatient stays to the patient population will increase the raw denial count, making UM efforts appear ineffective.

Instead, track the denial rate (denials per inpatient discharge). More often than not, the rate remains steady or improves. Hospitals must also consider their overturn rate. A high overturn rate means payers are challenging legitimate inpatient stays and losing, which is a defensible-status story, not a UM failure.

Why Net Revenue Wins

Inpatient care generates far more net revenue than observation care for a clinically comparable stay. Net revenue, more than cash collections alone, validates whether accepting slower payment on a much larger claim is the right tradeoff for the organization’s patient-status strategy. And because the cost structure for a given stay is largely similar regarding less patient status, that lift in net revenue generally improves EBITDA, though this could be tempered by increased costs if the change in status also drives a change in length of stay.

Higher AR days, plus higher net revenue, mean the organization is carrying more receivables and converting them into significantly more revenue than before. If net revenue per discharge is falling while CMI falls, that is a failure of the hospital’s revenue cycle. Net revenue per AA
(adjusted admissions) is the number that tells the true story of whether the new UR strategy is successful.

Reading the Four Together

CMI down, denials up, AR days up, net revenue up. That combination is evidence of a mix shift. Real deterioration looks different: CMI falling while revenue per case erodes, denials rising with weak overturn rates, AR aging within a single cohort rather than across the mix, and net revenue flat or falling.

Same four metrics, opposite story. Only segmentation tells you which one you’re in.

The Takeaway

Old benchmarks were built on a case mix that a successful UM program is designed to change. For organizations increasing appropriate inpatient capture, modest CMI dilution may become a natural consequence of changing patient-status mix.

As hospital reimbursement becomes more complex build dashboards around what distinguishes the two stories:

• Case-mix-adjusted views
• Denials per inpatient stay
• Dollars recovered and appeal success rate alongside denied dollars
• Inpatient and observation AR tracked separately
• Net revenue per adjusted admission (NRAA) as the metric that cuts through it all
• Final account write-offs as a check on whether the other metrics are telling the full story

Encourage alignment across UM, CDI, coding, and patient financial services before the quarterly review. If UM is capturing appropriate inpatient volume while finance is independently alarmed by CMI, the organization will inadvertently move back to leaving money and accuracy on the table. The goal is not to improve CMI, reduce AR days, or minimize denial counts. The goal is to maximize appropriate reimbursement while maintaining defensible clinical documentation and sustainable financial performance.

Don’t Let a Healthy Program Get “Corrected” Back into a Problem

If your CMI is dropping and your team can’t yet prove whether that’s dilution or decay, that’s the exact gap we help close. Brundage Group helps finance, revenue cycle, and clinical leaders distinguish between metric deterioration and metric distortion. By integrating UM, CDI, coding, denial, and financial performance data, organizations gain the visibility needed to determine whether a declining CMI reflects true operational weakness or the expected result of a changing patient-status mix.

The post When Good Utilization Management Makes Your Numbers Look Bad appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

As Senior Vice President of IT at Brundage Group, Aaron O’Brien leads the team developing the technology behind our physician-led services. From advanced analytics to workflow automation and client-facing solutions like Certus Radar, Certus Beacon, and Certus Navigator, his work helps hospitals gain greater visibility into their revenue cycle while enabling clinical teams to focus on informed, compliant decisions.

A Career Built on Solving Problems

Aaron’s career in technology began more than 20 years ago as a data analyst.

“I started as a data analyst and progressed from Microsoft Excel into advanced analytics, business intelligence, and technology leadership,” he says.

That experience eventually led him to Brundage Group.

“I really liked what Brundage Group was doing,” Aaron says. “Helping hospitals is meaningful work. My family has relied on hospitals throughout the years, so knowing our technology supports organizations providing patient care was something I wanted to be part of.”

Technology That Supports Clinical Expertise

Since joining Brundage Group nearly three years ago, Aaron has helped advance products that improve workflow efficiency, prioritize reviews, and provide actionable insights.

One of the biggest advancements has been the evolution of Certus Radar.

“We’ve focused on making it valuable not only from a financial perspective for hospitals but also as a complete product solution, from integrating with client systems to helping clients manage work and measure outcomes through Certus Beacon.”

For Aaron, technology isn’t replacing expertise.

“Our goal is to reduce the time our physicians and operational teams spend navigating workflows so they can focus on making the right clinical decision.”

Innovation Starts with Listening

Every product enhancement starts with client feedback.

“Our Business Development, Client Success, Operations, and Clinical teams work directly with hospitals every day, so they understand where the gaps and opportunities are.”

Aaron O’Brien, Senior VP of IT

Those insights, combined with clinical expertise, shape solutions that solve real-world challenges.

“Technology alone isn’t enough. You need the clinical perspective to make sure you’re building something that truly solves a problem.”

Keeping AI in Perspective

Aaron sees artificial intelligence (AI) as a way to improve efficiency, not replace clinical judgment.

Instead, AI can help prioritize records, streamline workflows, and automate routine work while physicians remain central to every meaningful decision.

“We’re big believers in keeping a human in the loop.”

Looking Ahead

Aaron is excited about the future of healthcare interoperability, a vision reflected in Certus Connect, Brundage Group’s latest technology offering.

By securely displaying electronic medical record data within Brundage Group’s workflow, Certus Connect streamlines reviews, reduces unnecessary system access, and shortens turnaround times.

“The goal is simple,” Aaron says. “Help our teams resolve cases faster while making the experience easier for our clients.”

While Aaron spends his days focused on software and product development, his perspective always comes back to people.

“We know what we do positively impacts hospitals,” he says. “I’d like to think those improvements help organizations better support their staff and improve patient outcomes.”

As healthcare technology continues to evolve, Aaron believes success will come from embracing innovation while maintaining a strong focus on security and trust.

As healthcare continues to evolve, Aaron believes organizations must embrace innovation thoughtfully.

“We’re living through one of the most disruptive periods in technology,” he says. “The organizations that succeed will be the ones that embrace innovation while maintaining a strong focus on security and trust.”

That philosophy continues to guide Aaron and his team as they build technology that strengthens collaboration, supports clinical expertise, and helps hospitals navigate an increasingly complex healthcare landscape.

The post Spotlight: Aaron O’Brien | Building Technology Behind Better Healthcare appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Why the Gaps Are So Easy to Miss

Revenue cycle data rarely lives in one place. UM tracks patient status. CDI and coding teams work from documentation. Denials get logged separately, often after the fact. Each team can see its own slice clearly. Almost no one has a single view across all four.

That fragmentation hides the real story. A hospital might be denying claims at a normal rate, appealing them well, and still be leaving significant money on the table, simply because no one has connected the dots between where status decisions are made and where reimbursement lands.

What a Data Assessment Actually Shows You

A Complimentary Data Assessment from Brundage Group pulls your UM, CDI, coding, and denial data into one picture. Instead of four teams each defending their own numbers, you get a single, objective view of where you’re capturing revenue well and where you’re not.

In one case, this kind of review helped a 1,000-bed Level 1 Trauma and Academic Medical Center identify a negative observation trend in Medicare Advantage patients. Working with hospital leadership on a combination of process changes and targeted staffing, the organization preserved over $1.68 million in net revenue in just over six weeks.

That’s not a hypothetical. That’s what happens when the data finally gets looked at as one story instead of four disconnected ones.

Why This Matters More Now

Payer scrutiny keeps increasing. Medicare Advantage plans review inpatient status more aggressively than traditional Medicare. Denial volume is climbing across the industry. In that environment, the hospitals that protect their margin are the ones who can see the full picture of their revenue cycle, not just the piece their department owns.

Waiting for next quarter’s numbers to reveal a problem means the revenue is already gone. A data assessment gets ahead of that by showing you the pattern before it shows up as a loss.

What to Expect

A Complimentary Data Assessment is a real look at your UM, CDI, coding, and denial data, done by people who understand how those pieces connect. You’ll walk away with a clear picture of where your revenue cycle is strong, where it’s leaking, and what’s worth prioritizing first.

There’s no cost and no commitment. Just a clearer view of what your data has been trying to tell you.

The post The Revenue You’ve Already Earned Might Be Sitting in Your Data appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Today, as Lead Clinical Coding Analyst at Brundage Group, Robin helps healthcare organizations strengthen DRG accuracy and reduce denial risk before claims are submitted. But her understanding of denial management and DRG integrity was built through a path that was anything but linear.

In fact, much of her expertise was built by working on the opposite side of the table.

From Physician Billing to Revenue Integrity

Robin’s healthcare career began in the late 1990s, providing medical billing services for physician practices while raising her children at home.

“I wanted to have my own business so I could be home with my kids,” she recalled. “This was during the dial-up internet era, so everything took a little longer, but it gave me exposure to a wide variety of specialties and how reimbursement worked.”

As payer requirements became increasingly complex, Robin found herself drawn to the broader challenges of healthcare reimbursement and documentation. After earning inpatient coding credentials, she transitioned into the hospital space and eventually discovered a passion for DRG auditing.

“I thought I was going to love coding,” she said. “What I realized was that I enjoyed auditing much more. I liked identifying problems, finding opportunities, and understanding why things happened.”

That curiosity ultimately led her into the payer world, where she spent years conducting DRG audits, developing recovery concepts, and reviewing provider appeals for some of the nation’s largest health plans.

Learning the Payer Playbook

Robin’s experience reviewing claims and appeals on behalf of payers gave her an uncommon advantage: she learned exactly what auditors look for when evaluating documentation, coding accuracy, and clinical support.

“I was reading the appeal letters hospitals submitted and deciding whether I agreed with them or not,” she explained. “That experience taught me what the auditor on the other side wants to see.”

Over time, Robin became known for her deep understanding of payer tactics and denial trends. Her unique perspective earned her the nickname “Queen of Denial,” which eventually inspired her to develop a denial analytics application.

The tool helped organizations identify denial patterns, track root causes, and uncover documentation gaps that contributed to reimbursement challenges.

“It allowed us to drill down into why denials were happening,” Robin said. “Instead of just looking at the denial itself, we could identify documentation issues, education opportunities, and patterns that needed attention.”

While technology has evolved significantly since then, the experience reinforced something Robin continues to believe today: understanding denial risk requires more than simply reacting to denials after they occur.

Moving from the Payer to Provider Side

After years of working for payers, Robin transitioned to the provider’s side.

“I guess I got a little burned out being on the payer’s side,” she stated.

She joined Brundage Group initially supporting denial management efforts. Around the same time, she began collaborating with Dr. Rao on what would eventually become Brundage Group’s DRG Integrity service line.

“Dr. Rao told me we were going to build a DRG program,” Robin said. “I’ve been involved from the beginning, helping develop the rules, workflows, and processes that support what we’re doing today.”

That work continues to evolve as Robin develops sophisticated review rules designed to identify claims with the highest likelihood of denial risk, documentation concerns, or reimbursement opportunities.

Why Denial Prevention Matters

While many organizations still view DRG reviews primarily as a revenue optimization strategy, Robin believes the industry’s biggest opportunity today is denial prevention.

With clinical validation denials continuing to increase, Robin sees firsthand how payer scrutiny affects hospitals and health systems.

“There’s really no end in sight to the denials,” she said. “The best opportunity is to catch issues before billing and give organizations a chance to address them proactively.”

That proactive approach is one of the reasons she strongly believes in pre-bill DRG review.

“Getting it right the first time is really what we’re trying to do,” Robin explained. “If organizations can identify documentation concerns, coding risks, or potential denial issues before billing, they’re in a much better position than trying to fix everything after the fact.”

A Different Approach to DRG Integrity

When asked what sets Brundage Group apart from other vendors, Robin points to the depth of review and the collaborative expertise behind every recommendation.

That multidisciplinary approach allows Brundage Group to identify risks that might otherwise be missed while helping organizations avoid recommendations that could create future denial exposure.

“We’re not interested in recommending something simply because it increases reimbursement,” Robin explained. “If we know it’s likely to create a clinical validation issue later, we’re going to tell the client that.”

For Robin, success isn’t measured by how many claims are touched. It’s measured by helping organizations submit accurate claims, reduce rework, and strengthen revenue integrity.

Looking Ahead

Even after more than two decades in healthcare, Robin remains energized by solving complex reimbursement challenges and finding new ways to improve the review process.

One area that particularly excites her is the opportunity to combine utilization management insights with DRG expertise earlier in the patient journey—helping identify opportunities before coding is even finalized.

“We’re always looking for ways to be more proactive,” she said. “The goal is to help organizations identify opportunities and risks as early as possible.”

That mindset—always asking what comes next and how processes can be improved—has been a constant throughout Robin’s career.

From physician billing and coding to payer audits, denial management, and DRG integrity, she’s spent more than 25 years understanding every side of the reimbursement process.

Today, healthcare organizations benefit from that experience every time she helps them prevent a denial before it happens.

And if there’s one thing Robin has learned along the way, it’s that sometimes the best way to win an appeal is to never need one in the first place

The post Spotlight: Robin Sewell — Turning Denials into Prevention appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

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

A chart came across our team recently, causing one of our coders to question whether a query was indicated without being leading. The patient was diagnosed with pneumonia, urinary tract infection (UTI), acute kidney injury (creatinine 2.52), and hypotension (MAP 65). There was an obvious Sepsis-3 query opportunity, but since the provider attributed the AKI and hypotension to dehydration, the coder felt a query could be construed as leading.

“If I query for sepsis now, could that be leading? The provider already gave the etiology.”

That hesitation is one of the most common, yet costly, reflexes in clinical documentation integrity (CDI). It stems from two separate issues. First, a misunderstanding of the current Query Practice Brief. Second, years of “payer conditioning.”

Myth #1: “The provider already answered, so a query would be leading.” 

This was the concern that gave our coders pause. And some would argue that this is “introducing a new diagnosis,” as mentioned in the current Query Practice Brief.

What the Brief Says:

“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.”

The clinical indicators were there for sepsis; thus, a query for sepsis would not be introducing a new diagnosis.

The provider’s attribution of hypotension and AKI to dehydration does not close the door. It simply establishes one possible explanation. The purpose of the query is not to overturn that conclusion. It is to reconcile two documented facts that have not yet been connected: an active infection with SOFA-scoreable organ dysfunction and documentation attributing that organ dysfunction to dehydration.

What would make the query leading is the execution:

Playing Doctor: Stating that the AKI and hypotension are organ dysfunction due to sepsis.

Unnatural Selection: Dropping dehydration as an option or presenting only the clinical indicators supporting sepsis while omitting those supporting volume depletion.

Name Dropping: Asking the provider to confirm sepsis rather than clarify the etiology.

Keep dehydration on the table, lay out all the relevant clinical indicators, and ask the provider to clarify what is driving the findings. The provider’s prior documentation is not an obstacle. It is simply one of the possible answers.

Myth #2: “Maybe dehydration really does explain it.” 

This is a related myth, and it is largely payer-driven.

The premise is that fluid-responsive hypotension or AKI cannot really represent sepsis. Querying, therefore, becomes chasing a diagnosis that will eventually be denied. This is where payer conditioning has quietly influenced how CDI specialists and coders think.

It is worth going back to the actual Sepsis-3 definition.

Sepsis-3 (Singer et al., JAMA, 2016) defines sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, with organ dysfunction operationalized as an acute increase in the SOFA score of 2 or more points attributable to the infection.

Hypotension drives the cardiovascular component. A MAP below 70 contributes one SOFA point. Creatinine drives the renal component. A creatinine between 2.0 and 3.4 mg/dL contributes two SOFA points. A patient with documented infection, a MAP below 70, and a creatinine of 2.52 already has a SOFA score of 3.

Nothing in the Sepsis-3 definition requires that organ dysfunction persist after a fluid bolus. The familiar “despite adequate fluids” or “in the absence of hypovolemia” language belongs to septic shock, the sickest subset of sepsis, not to sepsis itself.

The real question is attribution. Was the organ dysfunction caused (at least in part) by the infection, or solely dehydration?

In this record, there absolutely was a basis to query. Pneumonia as a source, SOFA-scoreable organ dysfunction, and a competing dehydration explanation created genuine etiologic ambiguity. That is precisely the situation a clinical query is intended to resolve. Uncertainty was not a reason to hold back. It was the reason to ask for clarification.

The Recommended Query:

Clinical indicators in the record: 

• ED Vitals: Heart Rate: 91 (Monitored) RR: 23 Blood Pressure: 80/50 SpO₂: 94% 
• H&P: Pneumonia documented on imaging; UTI + Streptococcus agalactiae 
• Labs: Creatinine 2.52 (normal baseline); WBC 14 
• Treatment: IV Fluids administered 1.75 liters; Vancomycin/ Zosyn IV ABX 
• Progress Note: Pneumonia, UTI, AKI and hypotension documented secondary to dehydration 

Query:

The record reflects active infections (pneumonia and UTI), as well as concurrent AKI and hypotension currently attributed to dehydration

Please clarify the etiology of the AKI and hypotension:

• Due to hypovolemia/dehydration 
• Due to sepsis secondary to pneumonia 
• Due to dehydration and sepsis 
• Clinically undetermined 
• Other (please specify) 

Notice what the query accomplishes:   

Any Query Response is a Win!

Regardless of how the provider responds, the record is stronger.

If the provider attributes the findings to sepsis, the diagnosis has been captured through a compliant, non-leading query. If the provider confirms dehydration as the sole etiology, the ambiguity has been resolved, and the documentation is stronger.

Either way, the objective has been achieved. A compliant query is not about obtaining a particular diagnosis. It is about replacing ambiguity with clarity. Clarity is what stands up to audit.

The post Query IQ: “But the Provider Already Labeled it” appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

• 1,438 procedures and services remain on the IPO list in CY 2026.
• CMS proposes to remove 637 less-complex services (approximately half of the remaining IPO services) from the following clinical families: auditory, digestive, endocrine, female genital, hemic and lymphatic systems, integumentary, male genital, maternity care and delivery, mediastinum and diaphragm, respiratory, and urinary in CY 2027.
• CMS will maintain the remaining clinical families through CY 2028.

The absence of a procedure from the IPO should not be interpreted as only appropriate in the hospital outpatient setting (70 FR 68696). CMS has emphasized the expectation that, in every case, the physician or surgeon and hospital will exercise their professional judgment and assess the risk of the procedure or service to the individual patient while considering the site of service and acting in that patient’s best interest (65 FR 18456). For procedures not included on the IPO, CMS will rely on the practitioner’s judgment to determine on a patient-by-patient basis whether or not a particular procedure is most appropriately performed in the inpatient setting (70 FR 68698).

• If CMS finalizes its proposal to remove these services for CY 2027, the remaining 801 procedures, which are more clinically complex in nature, would be removed from the IPO in the final transition year, CY 2028.
  • The remaining procedures are from the neurological family, cardiovascular family, solid organ, intestinal, and islet cell transplants and related services.
  • CMS agreed to wait to remove these more clinically complex and unique procedures, as well as certain invasive procedures involving craniectomy, craniotomy, and/or burr holes and cardiovascular procedures, until the last phase (90 FR 53788).

Today, if a procedure is on the IPO list, Medicare has already decided it warrants inpatient care. The ability to automatically bill these procedures as inpatient, regardless of the patient’s actual length of stay, disappears once the procedure is removed during the phase-out process.

Documentation becomes the deciding factor, not the procedure. For any procedure removed from the list, CMS expects the physician to make the inpatient-versus-outpatient call based on the individual patient. There’s no default answer anymore.

The two-midnight rule moves to center stage. Once a procedure comes off the IPO list, physicians need to document why they expect the patient will need two or more midnights of hospital care for Medicare beneficiaries, whether that’s driven by the complexity of the procedure itself or by something specific to the patient: comorbidities, risk factors, expected complications. Weak, incomplete, or missing documentation is exactly what invites a future medical necessity denial.

More cases will need Physician Advisor input in real time. As the IPO list disappears, more borderline cases will need a second clinical opinion to confirm inpatient status is appropriate, ideally before the claim goes out, not after a denial comes back.

This is a multi-year trend, not a one-time change. By CY 2028, the IPO list will go away entirely. Physicians and hospitals will be adjusting to this every year until that time, with the most complex procedures (cardiovascular, neurological, transplants) removed last.

The March 2026 Medicare Payment Advisory Commission Report to Congress on Medicare Payment Policy found, “about one-quarter of the decline in inpatient stays per capita since 2019 was from the shift of knee and hip replacements from inpatient to outpatient settings” following their removal from the inpatient-only list. To provide more perspective, in 2018, MS-DRG 470 (Major Joint Replacement without MCC) ranked first in both FFS Medicare volume and payments. Since then, it has fallen out of the top ten MS-DRGs with a 66% decline in inpatient volume.

The removal of hip replacements from the IPO list in 2018 provides a window into what hospitals can expect as procedures are removed until the complete elimination of the IPO list by January 1, 2028. The loss of the IPO list will further erode hospital margins without adequate documentation to support inpatient medical necessity. Although there will be an initial moratorium on medical necessity denials for these removed procedures for Medicare beneficiaries, private payers who base medical necessity decisions on the IPO list have no such mandate. Consequently, hospitals must act quickly to adjust to this significant change in medical necessity criteria for surgical cases.  

More cases will need UR review. Hospitals are already spending more on administrative functions associated with the clinical revenue cycle due to rising denial rates. The IPO list phase-out will put more strain on limited utilization review staff by increasing the volume of cases. Additionally, because these cases automatically qualified for inpatient services based solely upon the planned procedure, the industry lacks adequate tools to support this shift in review priorities. This uncertainty is likely to increase denial volumes immediately for payers who voluntarily made status determinations using the IPO list.

The post The End of the Medicare Inpatient-Only List appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Hospitals know the value of Physician Advisors — but building and sustaining an internal program is harder than it looks. Recruiting experienced clinicians, maintaining consistent coverage during evenings and weekends, and managing peak demand can all strain even well-resourced teams.

That’s why more hospitals are turning into flexible, hybrid Physician Advisor models that extend or enhance their existing capabilities. Rather than a one-size-fits-all approach, these arrangements allow organizations to select the level and type of support that best fits their specific needs, budget, and goals.

How Brundage Group Supports Your Team

Brundage Group’s Physician Advisors work directly alongside utilization management, coding, and denial management teams. Leveraging analytics and purpose-built technology, they identify at-risk cases early, ensuring appropriate patient status to increase appropriate reimbursement and help prevent avoidable denials.

Depending on your organization’s needs, Brundage Group provides:

• Flexible coverage during evenings, weekends, or high-volume periods
• Team augmentation to supplement your existing Physician Advisor staff
• Specialized expertise for complex cases and payer negotiations
• Expert Peer-to-peer support from scheduling through facilitation
• Documentation improvement and DRG optimization
• Workflow strengthening across utilization management processes
• Revenue protection while maintaining compliance

The Strategic Case for a Hybrid Model

For CFOs, hybrid Physician Advisor arrangements offer a compelling alternative to adding permanent headcount. They allow hospitals to scale resources to meet demand — whether that means filling coverage gaps, handling a surge in denials, or gaining specialized clinical expertise that doesn’t exist internally.

Beyond staffing flexibility, partnering with Brundage Group provides advantages that are difficult to replicate in-house:

• Broader perspective: Brundage Group’s advisors bring insights drawn from experience across dozens of health systems, not just one.
• Benchmarking and analytics: Access to industry data and a proprietary workflow platform that reduces delays, surfaces hidden revenue opportunities, and improves compliance.
• Reduced operational burden: External physician-led support lets internal teams focus on core clinical priorities rather than administrative complexity.
• Proven methodologies: Best practices in mid-revenue cycle management, delivered by experts who do this work every day.

Protecting Revenue in a Tightening Environment

As payer scrutiny intensifies and reimbursement rules grow more complex, hospitals need solutions that combine clinical expertise, technology, and adaptability. A hybrid Physician Advisor model does exactly that, protecting revenue, supporting compliance, and reinforcing long-term financial health without the overhead of a fully internal program.

Whether you’re looking to strengthen an existing Physician Advisor program or need targeted support with denials, utilization management, or automation, Brundage Group is ready to help.

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Part 3 of a 3 Part Series

In Part 1 of our series, we explained how the draft 2026 ACDIS/AHIMA Practice Brief addresses compliance with technology-generated and AI-assisted query standards. In Part 2, we clarified the Brief’s guidance on compliant query practice and its relationship to claim denials. In this final installment, we focus on the core issue: what documentation supports code assignment and why a compliant query response suffices once it becomes part of the permanent health record.

The draft of the updated 2026 ACDIS/AHIMA Practice Brief, “Guidelines for Achieving a Compliant Query Practice, dispels some common myths associated with clinical documentation, like the idea that a diagnosis must be documented throughout the health record to be reportable. This is not a requirement within the Official Guidelines for Coding and Reporting. The reality is that supportive clinical indicators will be present; otherwise, there would be no justification for a query. However, the terminology used to describe the condition may only be documented in ICD-10-CM terminology within the query. That is the whole purpose of a query: to represent the patient’s clinical scenario and the provider’s intent in terms that align with the billing code set used in that setting.

Payers often cite “the diagnosis only appeared on the query,” or the lack of consistent use of the coding term throughout the health record, or the absence of the diagnosis (in ICD-10 language) in the discharge summary as reasons to remove a clinically significant diagnosis that meets reporting requirements from the claim. Often, queries are issued to obtain an impactful diagnosis (e.g., one that adds a CC or MCC to the claim) that is clinically valid and reportable for inclusion in the discharge summary. This is a huge waste of limited resources and is annoying to most providers. The reference to diagnoses being in the discharge summary is from old coding guidance that advised that the principal diagnosis be listed and that all secondary diagnoses appear in the final diagnosis list or be reflected in the final diagnostic statement. However, since that time, coding guidance explicitly states that coders must review the entire record for diagnoses (not just the discharge summary).

The draft brief specifically states, “If a compliant query has been properly answered and authenticated by a responsible provider and is part of the permanent health record, it is sufficient for code assignment. The response to the query is not required to be repeated elsewhere in the health record.” When querying was first introduced, the preferred query format was open-ended, and the response had to be documented in a subsequent medical record note because there was no other way to include it in the permanent health record. In fact, CDIs used to spend a lot of time following up with providers to remind them to document their query response within the health record.

Open-ended queries were difficult for both the provider and the query professional. The provider did not know coding terminology, so the query response often failed to yield the desired result of clarifying existing documentation into terms that translate into diagnosis codes. The shift to multiple-choice queries began while health records were paper, but became the preferred query format during the transition to EMRs because it added efficiency to the query process for both query professionals and the provider being queried. Additionally, multiple-choice queries provide the provider with coding terms that appear to align with the clinical scenario, thereby increasing their efficacy.

One of the most important inclusions in the draft is the statement that “There is no specific direction as to where a diagnosis must be documented or how often the diagnosis must be documented to allow it to be reported.” Although the query practice brief, once finalized, is only industry guidance, this is an important statement to include in appeals when a diagnosis is challenged because it is documented using ICD-10-CM terminology only once.

Appealing payer denials can be a cumbersome task that requires more than coding or clinical knowledge. In today’s healthcare environment, where profits are limited for both payers and hospitals, those appealing payer denials need to be experts in healthcare regulations, coding, and medicine.

As query expectations change, healthcare organizations need practices that are both compliant and trustworthy, supporting accurate documentation and provider confidence.

The post 2026 Practice Brief Draft: Sources of Documentation for Claims Data appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Part 2 of a 3 Part Series

In Part 1, we explored how the draft 2026 ACDIS/AHIMA Practice Brief addresses technology-generated queries and affirms that AI-assisted documentation tools must meet the same compliance standards as traditional queries. In Part 2, we cover another key update: the Practice Brief’s effort to redefine compliant query practice and clarify how the guidance should, and should not, be used in payer reviews and claim disputes.

An unintended use of prior query practice briefs was their use as a payer denial tool. Query experts Cheryl Ericson, Senior Director of Clinical Policy and Education, and Robin Sewell, Lead Clinical Coding Analyst at Brundage Group, presented at last year’s National ACDIS conference on this topic. The updated 2026 ACDIS/AHIMA Practice Brief, “Guidelines for Achieving a Compliant Query Practice,” addresses this topic head-on by discussing the draft’s intent and limitations.

First, it is important to acknowledge the elephant in the room. Even though physicians are independently reimbursed for the services they provide, their documentation serves not only as the basis for their professional reimbursement but also impacts hospital finances. Clinical documentation impacts hospital reimbursement through a variety of mechanisms, ranging from determining patient status to MS-DRG assignments to performance on quality-of-care measures. Because clinical concepts often lack alignment with clinical code sets, queries are a necessary “communication tool” used to “ensure documentation integrity and the accuracy of diagnosis, procedure, or service code assignment for an individual encounter in any healthcare setting.”  Queries “support accurate, complete, and clinically valid documentation” so the provider’s intent can be reflected within administrative (claims) data.

The basis of ethical and compliant querying is identifying clinical misalignment with coding concepts that can result in an inaccurate representation of the patient when their encounter must be explained and justified using diagnosis and procedure codes. As payers look to cut expenditures, some have found success by removing diagnoses from claims when they determine a query is “noncompliant.” Their reasoning appears to be that the diagnosis obtained from a query the payer considers noncompliant is the fruit of the poisonous tree and, therefore, must be excluded.

The authors of this updated brief address this payer trend by clearly stating that the brief, “is not intended for use as a basis for denying claims or disputing clinical queries.”  Furthermore, it states that use of the brief “as a stand-alone rationale for claim denials, post-payment recovery, or adverse audit findings is inconsistent with its purpose and scope.” It is sufficient for query professionals to demonstrate “substantial compliance,” meaning the query meets general query requirements even if it may include an “isolated technical deviation, such as a minor formatting inconsistency, a missing source date on a single indicator, or a query title visitable to the provider that is descriptive but not diagnosis-directing.” In other words, the brief was never intended to serve as a payer-denial manual.

The 2026 Practice Brief Draft reinforces an important principle: compliant query practice is designed to support documentation integrity and accurate representation of the patient story, not serve as a standalone basis for claim denials. By clarifying the concept of substantial compliance and reaffirming the intended purpose of queries, the draft provides meaningful guidance for organizations navigating increased payer scrutiny.

Next week, we’ll explore “Sources of Documentation and Claims Data,” examining how the Practice Brief addresses the clinical evidence, documentation sources, and administrative data that support compliant query practices and accurate code assignment.

The post 2026 Practice Brief Draft: Defining a Compliant Query Practice appeared first on Physician-Led Advisory & Revenue Cycle Analytics.