The Sepsis Denial Crisis in Hospital Revenue Cycles Sepsis-related DRG downgrades are among the most financially damaging and preventable forms of revenue leakage hospitals face. When payers retrospectively challenge sepsis diagnoses and downgrade them to simple infections or pneumonia, the financial hit is immediate: $3,000 to $7,000 lost per case, and over $15,000 for more complex claims. But the impact goes deeper. These downgrades reduce your Case Mix Index (CMI), lowerin

The Problem Every month, physicians deliver complex, ongoing care to ESRD patients. But even when that care is delivered correctly, it...

When "Prior Processing Information Appears Incorrect" Costs You Money Let's face it - pediatric immunization billing is tricky. At the heart of this challenge is the critical relationship between three key elements: CPT® code 90460 (immunization administration with counseling), ICD-10 code Z23 (encounter for immunization), and the dreaded CARC 129 denial (prior processing information appears incorrect). When these three components don't work together properly, your revenue ta

1. Introduction When therapeutic exercise meets osteoarthritis in the medical billing landscape, precision becomes paramount. The relationship between CPT® 97110 (therapeutic exercises), ICD-10 M16.12 (unilateral primary osteoarthritis of the left hip), and CARC 273 (exceeded coverage guidelines) represents one of healthcare's most nuanced coding challenges. This intricate dance of procedural justification, diagnostic specificity, and policy adherence demands sophisticated un

Patient age significantly impacts medical billing, with older adults often incurring higher charges due to complex care needs and insurance

Understanding blood pressure monitoring codes: Learn when and how to use CPT 3079F for diastolic readings of 80-89

1. Introduction Understanding the intricate interplay between CPT® code 00142 (”Anesthesia For Procedures On Eye; Lens Surgery”), ICD-10 code H25.11 (”Age-Related Nuclear Cataract, Right Eye”), and CARC B7 ("This provider was not certified/eligible to be paid for this procedure/service on this date of service") is crucial for seasoned billing professionals. These codes are fundamental in the reimbursement workflow for cataract surgeries, and any misalignment can lead to denia