Outpatient E&M Audits in Transition: What the 2026 Proposed Physician Fee Schedule Means for Compliance

Following the release of the Centers for Medicare & Medicaid Services (CMS) proposed Physician Fee Schedule (PFS) for 2026, outpatient evaluation and management (E&M) coding and documentation once again stand at the forefront of compliance focus.

The proposed updates build on the 2025 Final Rule, but introduce nuanced shifts that will directly influence how organizations document, code, and defend E&M services. For health information management (HIM) and clinical documentation integrity (CDI) leaders, this transitional period signals an urgent need to prepare for new audit triggers and strengthen data governance across outpatient care. READ MORE

Getting Ahead of the RADV Audit Curve

In an ideal world, every diagnosis code you submit to the Centers for Medicare & Medicaid Services (CMS) would be backed by bulletproof documentation – the kind that would make any auditor nod in approval.

In reality, most plans are making thousands of these high-stakes bets every single day without realizing the magnitude of risk they’re assuming.

Risk Adjustment Data Validation (RADV) audits have been around long enough that most risk compliance teams treat them like routine fire drills: unpleasant, but manageable. What they don’t realize is that RADV has evolved into a multi-billion-dollar contest of statistical warfare, wherein arcane mathematical models determine winners and losers. And the stakes keep climbing every year. READ MORE

The Importance of Diagnosis Coding for Medicare Advantage

Clinical documentation integrity (CDI) professionals work in a variety of settings, and although I mostly focus on topics related to hospital inpatient billing, this week I want to focus on diagnosis coding related to risk adjustment within Medicare Advantage (MA) plan payments.

Enrollment in MA has surpassed that of traditional Medicare, and it is now the dominant healthcare delivery model for those eligible for Medicare benefits. The payment methodology for Medicare Part A and Medicare Part B is guided by the Inpatient Prospective Payment System (IPPS). However, Medicare Part C (MA Organizations) is governed by a different payment methodology.

Instead of paying healthcare providers directly, under Medicare Part C, monthly payments are made to private healthcare companies that provide insurance coverage for Medicare beneficiaries who enroll in their plan.

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