Changes in E&M Coding for 2027
The Centers for Medicare & Medicaid Services (CMS) is continuing its multi-year push toward payment accuracy, documentation integrity, and value-based care.
While the most visible 2027 updates so far focus on Medicare Advantage (MA) and broader payment policy, the ripple effects for evaluation and management (E&M) coding are significant. Providers should expect tighter documentation standards, expanded use of complexity-based add-on codes, and heightened scrutiny of medical necessity. To be clear, there is no finalized 2027 Physician Fee Schedule, but recent CMS policies emphasize upcoming changes. READ MORE
Healthcare Compliance in the Machine-Learning Era
Healthcare compliance has entered the machine-learning era, and most organizations have not yet noticed.
Providers are using artificial intelligence (AI) to generate documentation, surface reimbursable conditions, and tighten coding workflows. Regulators and payers are using AI to detect abnormal patterns, flag statistical outliers, and identify documentation that does not align with expected clinical behavior.
Both sides are operating faster than traditional human oversight can follow. That much has been said.
What has not been said clearly enough is this: both sides are increasingly using the same classes of technology: natural language processing (NLP). Predictive analytics. Anomaly detection. Generative models. Pattern recognition. Longitudinal modeling. READ MORE
Lessons Learned: Appealing Audits
The 30th Annual Compliance Institute for the Health Care Compliance Association (HCCA) is scheduled to take place in Orlando next week. If you are there, come by and hear me speak – or just say hey!
For decades, I have complained about the process of appealing audits from Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), or Unified Program Integrity Contractors (UPICs), which is often described as meaningless until the fifth level.
A more accurate description might be that it is structured like a maze where every exit leads to another form. For providers, the Medicare appeals system – overseen by the Centers for Medicare & Medicaid Services (CMS) – is cumbersome, expensive, and time-consuming, with fairness that can feel just out of reach until the very end. READ MORE