From prior authorizations to coding, regulatory news ranked high in popularity for revenue cycle leaders this summer.
This summer was a busy one for revenue cycle leaders as new regulations dropped, lawsuits were filed, and providers continued to fight prior authorization provisions.
Take a look at the stories that mattered most to our revenue cycle leaders this summer.
Nearly 400 new diagnosis codes coming this fall, CMS announces
CMS recently announced the addition of 395 new diagnosis codes, 25 deletions to the diagnosis code set, and 13 revisions. An ample amount of these changes pertains to reporting certain diseases, accidents and injuries, and social determinants of health (SDOH). As mentioned, these code updates will take effect on October 1.
The new diagnosis codes are spread throughout the code set, with several dozen pertaining to osteoporosis with fractures, retinopathy and muscle entrapment in the eye, and disease of the nervous system—including Parkinson’s disease and epilepsy.
Medical, insurer groups ask CMS to not implement prior authorization provisions
The American Hospital Association, the American Medical Association, the Blue Cross Blue Shield Association, and AHIP came together to urge CMS to not proceed with implementing proposed prior authorization standards that the organizations stated would be costly and conflicting.
In a letter penned to the federal agency, the groups argued that the provisions of the December 2022 Notice of Proposed Rule Making would be detrimental "due to conflicting regulatory proposals that would set the stage for multiple PA electronic standards and workflows and create the very same costly burdens that administrative simplification seeks to alleviate."
Cigna sued for allegedly using algorithm to deny claims
Cigna is on the wrong end of a class action lawsuit that alleges the payer improperly denied members' claims through an algorithm.
The lawsuit was filed in the Eastern District of California by two Cigna members who claim they were both denied payment due to Cigna's PXDX algorithm—one plaintiff was rejected for an ultrasound and the other was denied for a vitamin D test.
According to the lawsuit, PXDX allows doctors to automatically reject payments "in batches of hundreds or thousands at a time," enabling Cigna to bypass the legally-required individual physician review process.
How Johns Hopkins spent $5M and 108,478 hours on quality reporting in one year
CMS says it collects quality data from hospitals paid under the IPPS with the goal of driving quality improvement through measurement and transparency to help consumers make more informed decisions, however gathering this information for CMS is proving time consuming and expensive for hospitals.
The study published in JAMA set out to evaluate externally reported inpatient quality metrics for adult patients and estimate the cost of data collection and reporting, independent of quality-improvement efforts, and the conclusion was staggering.
Amanda Norris is the Director of Content for HealthLeaders.