Off the Record with Brian Murphy

I’m recently back from the 2025 ACDIS national conference, and as usual flush with the latest in CDI trends, education, and breaking news. And right at the top of my takeaways is a seemingly innocuous classification with big ramifications: admit type. 

What makes this a big deal? Some hospitals appear to be playing a bit fast and loose with  guidance from the National Uniform Billing Committee (NUBC) in order to classify surgical admits as “urgent” rather than the more accurate “elective.” Doing so removes them from certain PSIs that negatively impact quality metrics and indirect revenue. 

My guest is Penny Jefferson, manager of clinical documentation integrity at UC Davis Health. Penny co-presented the session with Cheryl Ericson at the ACDIS conference. On this show we discuss: 

• What is admit type, why is it important, and common misunderstandings (admit type is very different than admit status--IP/OP/observation) 

• Who is the NUBC, and what are the current rules as they stand around elective, urgent, and emergent? 

• Compelling data—deidentified, but real—presented at ACDIS that shows what appears to be clear gaming by some healthcare organizations of the assignment of admit type, specifically opting for urgent over elective 

• The dramatic impact this seemingly small change can have on quality scores: Reclassifying an elective procedure as urgent effectively circumvents PSI exclusions, allowing the case to be excluded from elective-only quality measures, such as PSI 10, 11, or 13. 

• Possible solutions including Penny’s ongoing work with the NUBC and request for additional rigor 

• Optimal way to ensure admit type accuracy in the current climate, from use of coding or CDI staff to additional training for admission staff 

• Why is her boss Tami Gomez so awesome, and Penny’s selection for the Off the Record Spotify playlist 

For additional reading 

• Inconsistent ‘Admit Type’ Reporting May Inflate Hospital Quality Scores, by Nina Youngstrom/Report on Medicare Compliance: https://compliancecosmos.org/inconsistent-admit-type-reporting-may-inflate-hospital-quality-scores  

Until about 6-7 years ago A.J. Hegg had little idea what the acronyms CDI or UM were, much less what they did or how they helped hospitals.  

Today the Essentia Health hospitalist is leading a new physician advisor program and making a big impact on his organization. Both from a quality and financial perspective, but also on the personal lives of a diverse team of physician advisors who have managed to incorporate life balance into their work. 

Listen in as we cover: 

• Hegg’s origin story into CDI, fueled (or perhaps pushed) by director Tracy Boldt  

• His role today—CDI vs. medicine, and division of responsibilities 

• Essentia Health’s physician advisor program—services covered, scope of work, and core responsibilities including UM and CDI simultaneously 

• Bringing back old-school CDI as it was once practiced (and still is in some corners)—at the elbow clarifications, conversations, provider education. And how it all meshes with Essentia’s existing CDI team. 

• Metrics, assistive technologies, and high-level dashboard

• Who the team is and how it functions—shift work and task based, structured for work-life balance and an emphasis on positive culture 

• Obtaining organizational buy-in and high-level ROI 

• A favorite hazy memory from the Encore casino in Boston, September 2021 ACDIS physician advisor exchange... 

Outpatient CDI is not a traditional discipline—and so it stands to reason that its practitioners don’t always hail from traditional backgrounds. 

One such person is Glenda Bocskovits. I’d call her a former transcriptionist, but she still practices that craft with the Mayo Clinic. But Glenda has since expanded her career into cutting edge practice as an outpatient CDI specialist with Catholic Health. 

We get into Glenda’s unique career path, the obstacles of breaking into CDI as a non-clinician, and address the eternal question: What is the ROI of OP CDI? We cover the following topics: 

• Transcription: That’s still done? It is (hear why). 

• The ROI of outpatient CDI  

• Catholic Health’s thorough process of OP CDI chart review: Prospective, current/pre-bill, and retrospective 

• Common conditions requiring clarification and what continues to trip up providers 

• A day in the life of: What Glenda’s job entails 

• Obstacles of getting into CDI as a non-nurse and strategies for landing elusive interviews 

• Glenda’s career motivations and song selection for the Off the Record Spotify playlist 

Social Determinants of Health, or SDOH, are a buzzword these days—but often little more. We acknowledge their importance, but actual progress on capture (and subsequent patient support) has been slow. To be fair real barriers including technological limitations and limited financial incentives stand in the way.

But my current guest understands better than most the major role SDOH play in patient health. He and his organization have developed a digital tool to facilitate capture and improve the lives of patients in their community. They’re making a difference.

Dr. Pablo Buitron de la Vega is Assistant Professor of Medicine, Medical Director, Preventive Medicine Residency, and Clinician Lead for the THRIVE Social Determinants of Health Program at Boston Medical Center / Boston University School of Medicine. A native of Ecuador, he’s made SDOH his mission.

On this show we cover:

• Dr. de la Vega’s long journey from Ecuador to U.S. physician, the obstacles he overcame, and how the experience shaped his mission as a provider
• Defining SDOH and common examples in his line of work as a Boston physician
• Basics of capture in ICD-10 and what makes SDOH difficult to collect
• Boston Medical Center’s SDOH capture tool, THRIVE: What it does, tangible benefits, and how your organization can get access
• Low-tech strategies for SDOH capture you can implement today
• Dr. de la Vega’s National Institutes of Health (NIH) grant to develop a triage tool to help address patients’ unmet social needs

I’ve been in the coding and CDI worlds since 2004, and in that time watched the rise of Facebook, YouTube and other social media. And as early 2011 or so I began to wonder, will anyone pair these two together?

When will see our first social media creator in the world of medical coding, making it his or her full-time gig?

I’m pleased to say that the day has arrived. Victoria Vo is a Medical Coding Educator, Auditor, YouTuber, Entrepreneur, and founder of Contempo Coding, LLC. Her YouTube channel has 187,000 subscribers and she's created close to 600 videos, some of which have racked up more than half a million views.

If you’ve met or seen Victoria you know this did not happen by chance. She’s a natural educator, charismatic and personable. But she’s also very knowledgeable about coding, passionate about the profession, and an outspoken industry advocate. We get into all this and more in a very social episode of Off the Record.

On this show we discuss:

• Victoria’s coding origin story
• Contempo Coding, the business and what it’s about
• Becoming a creator: Challenges and early side-hustle successes, timeline to earning her first $, and how she left coding to become full-time entrepreneur
• Three times she was recognized as a coding celebrity outside of AAPC conferences
• Advice for someone who wants to pursue content creation
• A joint ChatGPT rant (we both sound off on how we use it, and see it abused)
• What makes for a good coding professional
• Other fun stuff including her top resources and Off the Record Spotify playlist selection

Even if you’ve never seen The Godfather, you've probably heard its iconic line: “Just when I thought I was out, they pull me back in!"

That certainly applies to Sheila Duhon, National Director of Clinical Documentation Integrity for Steward Health Care. A year ago Sheila was headed toward semi-retirement, but changing events on the ground in the beleaguered healthcare system prompted her to get back into the game with her old organization.

Sheila is a 2022 CDI Professional of the Year award winner, a published author and passionate educator, but above all possesses a strong moral compass and a willingness to do what’s right for her CDI team and the patients they serve—one which has served her well in a tough spot.

On this show we cover:

• Sheila’s second act in CDI, from semi-retirement to full-time leadership role
• The cloud over Steward: How she puts that aside and focuses on the task at hand
• Her formative experiences as a nurse thrust into the ICU at age 19
• What makes for a good CDI educator, including her story of a challenging first educational session for a group of providers
• CDI as she sees it: A clarification that hospitals still miss, pros/cons of the current state of the profession
• Timeline toward retirement part 2 and final words of advice. Plus of course Sheila’s selection for the Off the Record Spotify playlist.

We all get excited—and rightfully so—at the rapid advance of clinical medicine. New treatments, therapies, and drugs save lives. But when you work in the revenue cycle, you know that payment mechanisms can significantly lag new technologies.

When codes don’t exist, or reimbursement is woefully inadequate, you have to take action. Petition, sometimes at the highest levels of government.

Jugna Shah is fighting for improved coverage and reimbursement for CAR-T and other cell and gene therapies, a trip that recently took her all the way to Capitol Hill. On this episode she talks about exciting work underway to improve healthcare accessibility and reimbursement, shaking hands with popular politicians, and of course some can’t miss documentation and coding tips.

On this show we cover:

• Jugna’s mission and the mission of Nimitt Consulting
• CAR-T and other cell and gene therapies: Current reimbursement mechanisms, insurance and coverage issues, and regulatory guidance
• Jugna’s advocacy efforts at the recent White House Cell and Gene Therapy Forum
• What came out of the Forum and what’s next given the recent change in administration
• What hospitals can do today to receive appropriate reimbursement for these life-saving therapies (she offers up some great advice on setting appropriate charges, citing the regulations)
• Where are we with drug administration (i.e., coding of injections/infusions)

We hear about lawsuits and false claims acts regularly, but did you know that many of these begin with someone working from inside the organization? Calling out bad behavior or noncompliance, sometimes again and again without being heard—before deciding to call on a third party for help?

You might have seen the recent headlines about New York insurer Independent Health, which agreed in December to pay $100M to settle allegations it had upcoded claims to inflate Medicare Advantage payment. But did you know the basis of the lawsuit was a whistleblower, and 12 years in the making?

My guest on Off the Record knows this very well. Mary Inman is a Partner at Whistleblower Partners LLP, and Head of International Whistleblower Practice for the firm. She also served as legal counsel in this very case.

I continue my “law and coding” start to 2025 with a fascinating guest and topic. On this show we discuss:

Who/what is a whistleblower, and the concept of qui tam

The mechanics/process of a whistleblower engaging a lawfirm: Are they working for their employer throughout reporting, discovery? Is gathering evidence to support their case without employer knowledge illegal?

What happens to a whistleblower who wins—or loses? How much can they stand to make, and is their career over?

New DOJ whistleblower project to encourage additional reporting

What some whistleblowers get wrong/false report or misunderstand

What hospitals/healthcare organizations can do to lessen the risk

Mary’s Off the Record Spotify playlist selection (I was disappointed it was not Judas Priest’s Breaking the Law)

Medicare Advantage. It’s everywhere you turn. From upcoding to denials, the huge and growing program—which now covers more lives than traditional Medicare, but is increasingly the target of local and federal scrutiny and a stream of endless OIG audit reports—seems to be in the news daily.

In a sea of online anger and noise, there’s a few voices of reason, reminding us about the regulations and guidelines and how MA should be conducting itself—at least in theory.

One such person is Richelle Marting. Richelle is an RHIA and a JD and owner of a host of coding credentials besides. As a Healthcare Reimbursement Attorney and Founder of Marting Law, LLC, she brings a unique legal viewpoint to medical coding, coverage, and payment. She knows what regulations bind Medicare Advantage plans—and how these are often skirted.

On this show we cover:

• Richelle’s start to 2025, personally and professionally

• What MA plans must cover and pay for, by law

• Prior authorization

• Under which circumstances MA plans can use internal coverage criteria

• How MA plans game the system: three sneaky tactics you won’t want to miss

• The latest on automated denials/use of AI

• Richelle’s answer to the question: Medicare Advantage: Yay or Nay?

• An interesting new year’s resolution and latest addition to the OTR Spotify playlist

Richelle’s desktop MA policy links:

Governing rules for Medicare Advantage: Code of Federal Regulations 42 Part 422: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-C

Final rule for MA plans (April 2023), 4201-F: https://www.federalregister.gov/documents/2023/04/12/2023-07115/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program

Medicare Internet-Only Manuals: https://www.cms.gov/medicare/regulations-guidance/manuals/internet-only-manuals-ioms

Medicare Advantage 2026 proposed rule: https://www.federalregister.gov/documents/2024/12/10/2024-27939/medicare-and-medicaid-programs-contract-year-2026-policy-and-technical-changes-to-the-medicare

Here we are, at the end of the year. And the end of another

For reasons that will soon become clear, I wanted to wrap up 2024 by pushing myself out of my comfort zone. Because this episode is about personal growth.

So here I am, doing my first ever solocast.

I bring you the Top 5 lessons learned over the year of Off the Record. These apply to mid-revenue cycle leaders, our core audience for #OTR, but they’re broad enough for anyone to adopt.

This is a tidy episode, just 26 minutes of distilled wisdom from several guests that I was honored to host.

Enjoy, Merry Christmas and Happy Holidays, and I’ll see you in