Kelly Simonelli

Blog Series: Part 2 – Active Diagnosis Coding for PDPM

In this 3-part blog series we will focus on issues that were identified in the recent OIG audit of PDPM records and MDS. The first area discussed the lack of documentation to support technical requirements. This second blog will focus on the requirements for coding diagnoses that meet the active diagnosis requirements. Billing and coding for medical services provided under the Centers for Medicare & Medicaid Services (CMS) should always be accurate and supported by…

Understanding Transitional Care Management (TCM) Services

Today’s healthcare system moves quickly and can be fragmented, making it more important than ever to ensure patients receive coordinated care after leaving the hospital or a skilled nursing facility. When several specialists are involved, there’s a higher risk of miscommunication, repeated treatments, and missed follow-up appointments. These issues can disrupt care and slow recovery. Transitional Care Management (TCM) services help address these risks. TCM provides structured support after discharge to lower readmissions, improve care…

CMS Interoperability and Prior Authorization Final Rule: A Compliance Reality Check for Payers and Providers

Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule, effective January 1, 2026, establishes new, enforceable standards for prior authorization and data sharing. It is intended to reduce administrative burden, improve transparency, and modernize data exchange across healthcare. But for many payers and providers, the reality of compliance is proving more complex than anticipated. As highlighted in a recent Healthcare Finance News article, organizations are facing significant challenges meeting the rule’s…