Bibliography

Sources are grouped by confidence tier, following the citation policy every chapter's further reading applies. Tier 1 are works we are confident exist; Tier 2 are real ideas whose exact publication we have not pinned down; Tier 3 are constructed teaching examples, labeled where they appear.

Tier 1 — Verified canonical sources

• United States ex rel. Kane v. Healthfirst, Inc., 120 F. Supp. 3d 370 (S.D.N.Y. 2015) — Case Study 1: first judicial interpretation of "identified" under the 60-day rule; motion-to-dismiss posture (facts were allegations). 2016 settlement (~\$2.95 million, with admissions) per the U.S. Attorney's Office (S.D.N.Y.) and New York AG public announcements — figure stated as "approximately," reader told to verify.
• 42 C.F.R. Part 405, Subpart I — the Medicare claim appeal procedures: redetermination, reconsideration, ALJ, Medicare Appeals Council, judicial review; filing windows (120/180/60/60/60 days), decision standards, escalation, and the reconsideration evidence rule (all evidence by level 2 absent good cause).
• 42 CFR Part 2 — federal confidentiality requirements for substance use disorder treatment records from federally assisted programs, operating in addition to HIPAA with different consent rules (§35.8).
• 42 CFR § 413.65 — provider-based status: location, ownership, clinical integration, and public awareness requirements. Governs §26.9's counterfactual.
• AAPC's current credential pages — CPC, COC, CIC, CPB, CRC, CPMA, the practice-management and documentation credentials, and the specialty credentials; plus the current apprentice designation requirements and the recognized routes to removing it. Behind §39.3 and §39.10.
• AAPC and the American Health Information Management Association (AHIMA) — their own current publications are the authority on their own credentials, experience and apprentice-removal requirements, specialty credential eligibility, and continuing-education requirements. All revised; read the current page and note the date.
• ACA § 2719 and 45 C.F.R. § 147.136 — internal appeals and external review: medical-judgment scope, the four-month request window, the state/federal division, the binding IRO decision.
• Affordable Care Act overpayment provision — Social Security Act §1128J(d) (report and return within 60 days of identification); implementing regulations at 42 CFR 401.305. ⚠️ The identification standard has been revised since first issued (2016 final rule; later revision aligning toward FCA knowledge standards) — the chapter repeatedly instructs "verify the current text," and every summary of the standard in Ch. 31 is written to survive either version.
• AHIMA's current credential pages — CCA, CCS, CCS-P, RHIT, RHIA, and the documentation-integrity, data-analytics, and privacy credentials; the RHIT/RHIA eligibility page carries the degree requirement. Behind §39.4.
• Anti-Kickback Statute (42 U.S.C. §1320a-7b(b)) and the Civil Monetary Penalties Law beneficiary-inducement provisions — the §31.7 compliance frame for routine cost-sharing waivers.
• Balanced Budget Act of 1997 (the statutory direction to risk-adjust Medicare managed care payment) and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (the direction that produced the comprehensive CMS-HCC model phased in from 2004).
• CAHIIM — Commission on Accreditation for Health Informatics and Information Management Education — and its accredited-program directory. The prerequisite check for the RHIT and RHIA pathways; §39.4's highest-consequence lookup.
• CAQH CORE operating rules for the 835 and for EFT/ERA — including reassociation of an EFT with its remittance, the mechanism for matching a deposit to the document that explains it. Free.
• CAQH CORE. Free. The operating rules, plus plain-language explanation of what an eligibility or claim status response must actually tell you.
• Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC), maintained and published through the Washington Publishing Company code list pages. Free to search. Updated on a schedule — codes are added, modified, and deactivated. The official description is frequently more precise than the one software displays, which matters most for CO-97.
• CMS / Medicare Administrative Contractor voluntary refund processes; state Medicaid refund processes.
• CMS EDI pages and Medicare EDI enrollment materials. Free, and unusually clear that EDI, ERA, and EFT enrollments are separate — §27.5's three-enrollment table.
• CMS esMD documentation. Free. Note what it is for (responding to review contractor requests) and what it is not (a general claims-attachment mechanism).
• CMS telehealth policy pages and the list of Medicare telehealth services — the list this book refuses to reproduce, because it changes; check the current page and its date. State telehealth and licensure law sits on top of it and is outside this book.
• CMS Voluntary Self-Referral Disclosure Protocol (SRDP) — the physician self-referral law route.
• CMS's published ICD-10 transition metrics from the period following October 1, 2015. Characterized rather than quoted in the case study — read the published figures at the source.
• Consolidated Appropriations Act, 2021, §122 — the phase-down of Medicare coinsurance for a screening colonoscopy that becomes diagnostic (Account 22-9107; percentage steps down by calendar year — verify current).
• CPT Category II codes and their reporting guidelines (American Medical Association), including the performance measure exclusion modifiers 1P, 2P, 3P, 8P. Revised annually.
• Each organization's code of ethics and professional-conduct or disciplinary procedure. Behind §39.4's ⚖️ and §39.11; paired with Ch. 5 §5.10.
• Each organization's continuing-education requirements, approved-activity list, reporting process, and reinstatement terms. Behind §39.11.
• Each organization's published testing-accommodations process, including the documentation it requires. Behind §39.9's opening, and the reason that section leads with accommodations rather than closing with them.
• ERISA, 29 U.S.C. § 1001 et seq., and the DOL claims-procedure regulation, 29 C.F.R. § 2560.503-1 — member appeal timelines (≥180 days), the right to the criteria and rationale free of charge, authorized-representative mechanics. (Introduced in Ch. 2; used here.)
• Fair Debt Collection Practices Act — agency conduct on placed accounts.
• False Claims Act (31 U.S.C. §§ 3729–3733) — behind §40.5's "knowingly" discussion and §40.8's sentence that a function can be delegated and the attestation cannot.
• False Claims Act, 31 U.S.C. §§ 3729–3733, and the U.S. Department of Justice's public announcements of resolved health care matters, including the nationwide ICD investigation and its 2013 published medical review framework ("resolution model"). Figures and participant counts are in the Department's own releases; this chapter asserts none. A settlement resolves allegations without a determination of liability.
• HIPAA (1996), administrative simplification, and the Transactions and Code Sets requirements designating standard code sets for covered electronic transactions. Case Study 1's third inflection point; Ch. 27 §27.1 covers what it standardized and what it did not.
• HIPAA Administrative Simplification regulations, 45 CFR Parts 160 and 162. Free. Part 162 is the transactions and code sets rule — the legal basis for §27.1, including adopted standards, code sets, and identifiers.
• HIPAA Privacy and Security Rules and the HITECH Act — the business associate relationship, obligations reaching subcontractors, and the minimum necessary standard; the framework behind §40.8. Office for Civil Rights guidance accompanies the rules.
• IRC §501(r) (added by the Affordable Care Act) and its regulations — the FAP requirement, amounts generally billed, extraordinary collection actions, and reasonable efforts. IRS charitable-hospital guidance pages.
• IRC §501(r) and its regulations — financial assistance policies, extraordinary collection actions, reasonable-efforts sequencing for tax-exempt hospitals (§31.10).
• LCDs, NCDs, and billing and coding articles — Ch. 22 §22.4. A coverage denial cites a policy and the policy has a supporting diagnosis list.
• MAC appeals pages and current forms — CMS-20027 (redetermination request), CMS-20033 (reconsideration request), CMS-1696 (appointment of representative). Forms are revised; always use current versions.
• Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Quality Payment Program resource library (qpp.cms.gov) — the authority for MIPS categories, weights, thresholds, measure specifications, and MIPS Value Pathways. Annual.
• Medicare Claims Processing Manual (CMS Pub. 100-04) — free, searchable; the authority behind much of the claims, review, and appeals material this chapter assembles.
• Medicare Claims Processing Manual, CMS Pub. 100-04, Chapter 29 — "Appeals of Claims Decisions." The operational rulebook. ⚠️ The Manual's chapter 29 is appeals; this book's Chapter 29 is denials — cite carefully.
• Medicare Financial Management Manual (Pub. 100-06) — overpayment and recoupment mechanics, voluntary refunds, and the limitation-on-recoupment (appeal-pauses-offset) provisions §31.9 sketches with a verify-current-timelines label.
• Medicare participation, assignment, and limiting charge rules and Medicaid billing restrictions (Ch. 3) — the pre-existing balance billing prohibitions §32.4 builds on.
• Medicare Program Integrity Manual (CMS Pub. 100-08) — the review and audit counterpart.
• Medicare Secondary Payer materials, for §28.10's coordination; Ch. 24 §24.7's questionnaire determines the order.
• Medicare Shared Savings Program regulations, 42 CFR Part 425, and CMS's Shared Savings Program pages — benchmarks, attribution methodology, minimum savings rates, sharing rates, the quality performance standard, and the risk score growth cap.
• Mental Health Parity and Addiction Equity Act — statutory background for §35.8's observation about administrative burden in behavioral health coverage.
• MREP and PC-Print — CMS's free software for reading Medicare electronic remittances (professional and institutional). Free; if you bill Medicare and cannot read your 835s, these exist.
• National coverage determinations and the Medicare Coverage Database (CMS) — including the national coverage determination for implantable cardioverter defibrillators and its waiting periods, which is Case Study 1's subject. Also the MAC-level LCDs and billing-and-coding articles for the specialty's top services.
• NCCI Policy Manual and the quarterly PTP edit files, CMS — the national standard and the modifier indicators cited in edit appeals (Ch. 21).
• NCCI Policy Manual for Medicare Services (CMS, free; annual manual, quarterly edit files) — one chapter per CPT section, in prose, with rationale; the fastest way to learn what a specialty's families bundle.
• NCCI Policy Manual, PTP edit files, and MUE files, CMS. Free and downloadable. The triage's second branch reads the modifier indicator and the MAI.
• NCDs, LCDs, and billing and coding articles (Ch. 22) — the standard argued in Medicare coverage appeals.
• Official UB-04 Data Specifications Manual, National Uniform Billing Committee. The authority on every form locator, the full code sets, and the revenue code list. Subscription.
• OIG Self-Disclosure Protocol — eligibility, content requirements, minimum settlement amounts, the presumption regarding corporate integrity agreements, and the tolling of the sixty-day obligation from an acceptable submission.
• OIG Work Plan — recurring credit-balance and overpayment-retention review items.
• OIG Work Plan, oig.hhs.gov. Free, updated. A denial category overlapping a Work Plan item is one where prevention is worth more than usual — the pattern that denies is the pattern that gets audited.
• OMHA (hhs.gov/about/agencies/omha) — ALJ procedures and the amount-in-controversy thresholds, which adjust every calendar year.
• Omnibus Budget Reconciliation Act of 1989 and the resource-based relative value scale, phased in beginning January 1, 1992. Case Study 1's second inflection point; Ch. 23 carries the arithmetic.
• Payer companion guides — Ch. 27 §27.1, the fourth time this book sends the reader to one. The source for payer-specific requirements a scrubber rule should encode.
• Payer companion guides, per payer. Free, published by every payer of any size. The document that resolves every situational element — §27.1's whole argument, and the fourth time this book has told the reader to read one (after Chs. 14, 21, 25).
• Payer medical and reimbursement policies. Free on every major payer's provider site. §29.4's triage says get the policy first for a proprietary edit; this is where.
• Place of service code set (CMS) — 02 and 10 for telehealth; the field's payment consequence is Chapter 23 §23.5's and the form field is Chapter 25 §25.8's.
• Public record for Case Study 1: the American Hospital Association v. Burwell/Azar docket (D.D.C. and D.C. Cir.), the court-ordered backlog reduction schedule (19%/49%/75%/elimination by end of FY2022) and HHS's quarterly status reports; GAO and HHS OIG reports on the Medicare appeals backlog; CMS's published settlement terms — the 2014 hospital inpatient-status settlement at 68% of net allowed and the 2018 Low Volume Appeals settlement at 62%; the Family Rehabilitation recoupment litigation (5th Cir.).
• QMB program materials — the billing prohibition Ch. 3 introduced. Free and specific.
• RAT-STATS (HHS OIG) — the government's free statistical sampling and estimation software, with its companion documentation.
• Social Security Amendments of 1983 and the inpatient prospective payment system — the moment a hospital's payment became a function of its coded record. Case Study 1's first inflection point; Ch. 33 §33.1 carries the payment half.
• State of Washington v. Providence Health & Services — Case Study 2: WA AG complaint (February 2022) under the state charity care law (RCW ch. 70.170) and Consumer Protection Act; 2024 resolution (reported ~\$137M debt forgiveness + ~\$20M refunds ≈ \$158M, on the order of 100,000 patients) per the AG's public announcement — reported figures, reader told to verify. Providence contested aspects of the characterization; noted in the case study.
• The 1995 and 1997 E/M Documentation Guidelines — the retired scoring conventions the case study is about. Still relevant to records predating the change and to E/M families revised later.
• The 2021 revision of the office and outpatient evaluation and management guidelines. The same lesson inside one code set; Ch. 15 §15.3.
• The AMA's published office/outpatient E/M guidelines effective January 1, 2021, and the CPT code book carrying them — the primary document for the change that retired history and examination as level-determining elements for that family.
• The annual OPPS/ASC final rule (Federal Register; CMS OPPS rulemaking pages). The CY2014 final rule replaced the five hospital outpatient clinic visit E/M levels with G0463 and retained the five ED levels; the rulemaking record across the 2000s — the alternatives considered and the published principles for hospitals' own internal facility leveling guidelines — is Case Study 2's primary source.
• The Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)) and the Civil Monetary Penalties Law beneficiary-inducement provisions — the routine cost-sharing waiver problem (§32.8), with OIG guidance on permissible need-based waivers.
• The Bureau of Labor Statistics occupational profile covering medical records and health information work — a federal statistical product with state and metropolitan tables, which are the part that matters. Read the methodology note: what the occupation includes changes what the number means.
• The CMS/AMA joint guidance of July 2015 on the twelve-month flexibility for Medicare Part B claims regarding code specificity within the correct family. Widely mischaracterized at the time as a further delay; the document settles what it said.
• The current candidate handbook or examination policy for the reader's specific exam, published by the organization administering it. The single most important source in this chapter: eligibility, registration, fees, format, delivery mode, permitted materials including the code-book annotation and edition rules, identification requirements, retake and reschedule policy. The primary source behind §39.6, §39.8, and §39.9, and the document §39.8 explicitly defers to rather than paraphrasing.
• The CY2019 Medicare Physician Fee Schedule final rule — finalizes a single blended payment rate for office/outpatient E/M levels 2 through 4 effective CY2021, with add-on codes and documentation flexibilities.
• The CY2020 Medicare Physician Fee Schedule final rule — declines to implement it and aligns instead with the revised office/outpatient E/M code set effective January 1, 2021. Read the two as a pair and in order.
• The exam content outline (blueprint) for the credential — the published domains and their approximate weights. The authority behind §39.6's "shape of the content" and the document §39.7's study plan is built against.
• The Fair Debt Collection Practices Act and the Consumer Financial Protection Bureau's debt-collection and medical-debt materials.
• The False Claims Act (31 U.S.C. §§ 3729–3733) — the legal exposure that makes an employer's verification problem a compliance problem rather than a quality one. §39.1's third argument.
• The HHS final rule adopting ICD-10-CM and ICD-10-PCS and the subsequent final rule delaying the compliance date — the 2013 date, then the 2014 date.
• The Hospital Price Transparency rule, 45 CFR part 180 (effective January 1, 2021) — the machine-readable file, the shoppable services display, and CMS's published enforcement actions.
• The ICD-10-CM Official Guidelines for Coding and Reporting and the NCCI Policy Manual — both free, both in §39.7's study plan (weeks 3 and 9), and named here because a chapter that has just discussed the cost of certification should say which authorities cost nothing.
• The No Surprises Act (Division BB, Consolidated Appropriations Act, 2021; enacted December 2020, effective January 1, 2022) and its implementing regulations — balance billing protections, qualified payment amount, notice and consent, good faith estimates, patient-provider dispute resolution, and federal IDR. CMS's cms.gov/nosurprises pages, provider and consumer sides.
• The Protecting Access to Medicare Act of 2014 (PAMA) — the statutory provision prohibiting HHS from adopting ICD-10 before October 1, 2015. The delay the case study turns on, passed inside a bill principally about something else.
• The reader's own denial log, with the fields Chapter 29 §29.7 specifies — root cause category and outcome being the two most often omitted and the two that matter. Sorting it by the allowed amount on the denied line is the analytical move §40.3 asks for.
• The reader's own payroll and overhead records — the fully loaded cost of a business-office hour. Not a publication, and the most important input to §40.2. Chapter 31 §31.7 establishes that computing it takes about an hour with a bookkeeper.
• The transition to ICD-10-CM and ICD-10-PCS on October 1, 2015, and the statutory delay that fixed that date in 2014. Case Study 1's fourth inflection point and Case Study 2's documented reversal.
• The Transparency in Coverage rules — the payer-side machine-readable files and member cost tools.
• Washington Publishing Company (WPC) code lists — claim status category codes, claim status codes, claim adjustment reason codes, remittance advice remark codes. Free to look up, which is what makes a 277CA's A7:562 resolvable.
• X12 835 implementation guide (TR3) — sold. Defines the provider-level adjustment section, the loop structure, and the balancing rules.
• X12 technical reports (TR3s) for 837P, 837I, 835, 270/271, 276/277, 278. x12.org. Sold. Every argument about "what the standard requires" is settled by one of these.
• Your own contracts. §28.8's step 1. The multiplier, the base schedule, the year of that schedule, the carve-outs, the lesser-of provision.
• American Hospital Association v. Azar — the U.S. District Court for the District of Columbia's 2019 decision setting aside the CY 2019 clinic-visit site-neutral policy, and the D.C. Circuit's 2020 reversal upholding it; the Supreme Court declined review. Case Study 1's primary source.
• American Hospital Association v. Becerra, Supreme Court of the United States (2022) — the unanimous decision on Medicare's payment rate for 340B-acquired drugs, and CMS's subsequent remedy rulemaking (lump-sum payment plus a prospective conversion-factor offset). Case Study 2's primary source.
• Medicare Claims Processing Manual, CMS Publication 100-04 — the operational rulebook for claim content and processing.
• 2021 Evaluation and Management office visit guidelines (AMA CPT E/M guidelines and the corresponding CMS rulemaking) — the removal of history and examination as office visit level drivers.
• 42 CFR 413.65 — provider-based status requirements; the rule underneath the two-claim arrangement of §34.8 and Chapter 26 §26.9.
• 42 CFR Part 412 — the IPPS regulation: transfer rule, outlier payments, HAC payment provision.
• 42 CFR Part 419 — the OPPS regulation; 42 CFR Part 416 — ambulatory surgical services.
• Affordable Care Act overpayment provision, 42 U.S.C. § 1320a-7k(d), and the implementing regulations on reporting and returning overpayments, including the treatment of "identification" and reasonable diligence.
• Affordable Care Act preventive services requirements, and federal agency FAQ guidance on polyp removal during a screening colonoscopy.
• AHA Coding Clinic for ICD-10-CM and ICD-10-PCS — the recognized source of official coding advice, published quarterly by the AHA Central Office. Subscription.
• AHIMA and ACDIS joint guidance on achieving a compliant query practice; ACDIS code of ethics for CDI professionals; AHIMA standards of ethical coding. Tier 1 as the governing professional standard for §38.3 — and revised repeatedly. Cite only the current edition, from the organization.
• AHIMA guidance on amendments, corrections, and deletions in the health record, and on defining the legal health record.
• AHIMA practice briefs on query practice, and joint AHIMA/ACDIS guidance on achieving a compliant query.
• American Hospital Association v. Azar, D.C. Cir. (2020) — upheld the Hospital Price Transparency rule.
• American Medical Association CPT resources — materials on the CPT Editorial Panel process, meeting agendas and actions, the code application process, and Category III code conventions including the archival period.
• Annual Physician Fee Schedule proposed and final rules, Federal Register. Proposed in summer with a comment period; final around November; effective January 1. The final rule's responses to comments explain the changes.
• Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b), and Office of Inspector General guidance, Special Fraud Alerts, and Advisory Opinions on routine waiver of copayments and deductibles.
• Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b), and the physician self-referral law, 42 U.S.C. § 1395nn — the two statutes that decide which disclosure door applies.
• Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b), and the safe harbor regulations at 42 C.F.R. § 1001.952.
• Balanced Budget Act of 1997 — the statute directing a prospective outpatient payment system; OPPS effective August 1, 2000.
• Bipartisan Budget Act of 2015, §603 — site-neutral payment for non-excepted off-campus provider-based departments; origin of the PO/PN modifier distinction.
• Centers for Medicare & Medicaid Services (CMS), cms.gov — the primary authority for Medicare payment, coverage, coding, and program integrity. All materials free.
• Civil Monetary Penalties Law, 42 U.S.C. § 1320a-7a, and 42 C.F.R. Part 1003. Penalty amounts are inflation-adjusted and must be verified currently.
• Claim status category and status codes — same pages. Needed to report rejections beside denials; the two do not share a vocabulary.
• Claim status category codes and claim status codes — same pages; Ch. 27's 277CA vocabulary.
• CMS Risk Adjustment Data Validation (RADV) program pages, and the contract-level RADV final rule, Federal Register, January 2023 — extrapolation from payment year 2018 and the decision not to apply a fee-for-service adjuster. Preamble as well as text. Verify subsequent rulemaking and the status of the litigation.
• CMS ambulance guidance, including origin and destination modifier definitions and coverage requirements.
• CMS and NCHS ICD-10-CM code files and annual addenda — the record of revisions to the diabetes long-term-drug-therapy status codes and to the dementia categories.
• CMS Clinical Laboratory Improvement Amendments guidance — the published list of waived tests, the certificate types and their requirements, and the provider-performed microscopy procedure list.
• CMS Comprehensive Error Rate Testing (CERT) pages and the annual Medicare Fee-for-Service supplemental improper payment data, including the composition of the rate by error category.
• CMS Global Surgery Booklet, Medicare Learning Network. Free.
• CMS guidance establishing the X{EPSU} modifiers (XE, XS, XP, XU) as more specific alternatives to modifier 59.
• CMS guidance on anesthesia medical direction requirements.
• CMS guidance on assignment and on participating versus non-participating providers, including the limiting charge.
• CMS guidance on billing Qualified Medicare Beneficiaries — the prohibition on billing QMBs for Medicare cost sharing.
• CMS guidance on Condition Code 44 and the post-discharge self-audit process.
• CMS guidance on hospital emergency department facility leveling, including CMS's decision not to publish national criteria and the expectations facility-developed criteria must meet.
• CMS guidance on modifiers GA, GX, GY, and GZ.
• CMS guidance on outpatient therapy thresholds, the KX modifier, and the targeted medical review threshold.
• CMS guidance on prolonged services, including HCPCS Level II code G2212 and its threshold.
• CMS guidance on split (or shared) visits, including the current definition of the substantive portion. Verify annually; this definition has changed more than once.
• CMS guidance on the anti-markup payment limitation and purchased diagnostic tests.
• CMS guidance on the JW and JZ modifiers, including applicable drugs, container types, and documentation expectations.
• CMS guidance on the Medicare Secondary Payer questionnaire, including model questions and administration frequency.
• CMS guidance on the National Provider Identifier, including the Type 1 / Type 2 distinction and enumeration requirements. NPPES, the enumeration system, is public and searchable.
• CMS guidance on the two-midnight benchmark, in inpatient prospective payment system rulemaking and subsequent sub-regulatory guidance.
• CMS hospital price transparency requirements (machine-readable file), introduced Ch. 23 §23.8.
• CMS interim guidance on Excludes1 (2015) and its incorporation into the Official Guidelines — the basis for Case Study 1.
• CMS interoperability and prior authorization rulemaking — decision timeframes, the requirement to state a specific denial reason, and public reporting of prior authorization metrics, on staged compliance dates.
• CMS materials on Risk Adjustment Data Validation (RADV) audits.
• CMS Medicare Advantage risk adjustment program materials, including the annual Advance Notice and Rate Announcement for the Medicare Advantage and Part D programs — the authoritative source for the model version, phase-in schedule, normalization factors, coding intensity adjustment, and county benchmarks.
• CMS Medicare Fee-for-Service Recovery Audit Program pages, and each RAC's published approved-issues list, record-request limits, and discussion-period rules.
• CMS Medicare Learning Network (MLN) educational products — practitioner-oriented free guidance on nearly every topic in this book.
• CMS operating rules for eligibility and claim status transactions, which define minimum data content and exist to reduce the variation the standards permit.
• CMS place of service code set and guidance.
• CMS post-transition ICD-10 metrics and the transition accommodation permitting valid codes from the correct family for a defined period.
• CMS preventive services materials and Medicare Learning Network products on covered screenings, frequencies, and coding requirements.
• CMS program-integrity pages for the Unified Program Integrity Contractors, including jurisdictions and the payment-suspension authority.
• CMS public utilization data by provider and service. Free; the source of outlier analysis.
• CMS published guidance on the use of algorithms and artificial intelligence in Medicare Advantage coverage decisions — the clarification that a tool may assist a determination and may not be the basis for one. Case Study 1.
• CMS Targeted Probe and Educate program pages — round structure, probe sample sizes, the education component, and post-final-round referral.
• Commercial payer medical policies.
• Consolidated Appropriations Act, 2021, § 122 — the statutory phase-down of Medicare beneficiary coinsurance for a screening colonoscopy that becomes diagnostic. The percentage steps down on a published schedule; verify currently.
• Consolidated Appropriations Act, 2021, §122 — the phase-down of beneficiary coinsurance for a planned colorectal cancer screening that becomes diagnostic, with CMS's current guidance on the phase-down schedule and modifier PT. The current step is a calendar-year lookup.
• Consolidated Appropriations Act, 2023 — decoupled continuous enrollment from the public health emergency and set the March 31, 2023 date.
• CPT Anesthesia guidelines — the definition of anesthesia time, the physical status modifiers, and qualifying circumstances.
• CPT Assistant, American Medical Association — the official publication providing guidance on CPT coding. Subscription. The CPT analogue of Coding Clinic.
• CPT Assistant. American Medical Association. Subscription. Extensive coverage of modifiers 25 and 59.
• CPT critical care guidelines, including the complete list of bundled services.
• CPT Editorial Panel published actions and Category III code listings — additions, conversions to Category I, and archived codes. The documented basis for Case Study 1.
• CPT injection and infusion guidelines — the hierarchy, the initial/sequential/concurrent definitions, and the minimum durations distinguishing an infusion from a push.
• CPT medical decision making table, published with the E/M guidelines.
• CPT moderate sedation guidelines and code descriptors, including the intraservice time definition and the independent trained observer requirement.
• CPT organ or disease-oriented panel definitions, listing each panel's component tests.
• CPT parenthetical notes throughout both sections, including the "(separate procedure)" designation.
• CPT physical medicine and rehabilitation guidelines, including which codes are timed.
• CPT professional edition, current year, American Medical Association. No free equivalent exists. The introduction and symbol key; the Surgery section guidelines; the Evaluation and Management guidelines; the appendix summarizing additions, deletions, and revisions; and the add-on code and modifier-51-exempt appendices.
• CPT section guidelines addressing modifier use, particularly the Surgery guidelines on the surgical package and the global-period modifiers.
• CPT subsection guidelines for the Integumentary and Musculoskeletal systems — the lesion measurement rule, repair classifications and the adding rule, the Mohs requirements, and the fracture treatment definitions.
• Current Procedural Terminology (CPT), Evaluation and Management guidelines, current edition. American Medical Association. The governing definitions of addressed, stable, unique test, external, independent historian, discussion, and the complete risk table.
• Current Procedural Terminology (CPT), modifier appendix, current edition. American Medical Association. The complete modifier list with full descriptors.
• Current Procedural Terminology (CPT), Radiology, Pathology and Laboratory, and Medicine guidelines, current edition — ultrasound completeness element lists, the contrast definition, panel component lists, and the injection and infusion hierarchy.
• Current Procedural Terminology (CPT), Surgery guidelines, current edition. American Medical Association. The source of the surgical package.
• Deficit Reduction Act of 2005, §5001(c) — POA reporting and the hospital-acquired condition payment provision; CMS HAC/POA program guidance as the current-state reference.
• Department of Justice annual False Claims Act statistics, including health care and qui tam shares. Look up the current year.
• Department of Justice press releases and settlement announcements involving unbundling and modifier misuse.
• Department of Justice public statements and filings in risk-adjustment matters. Note that the record contains matters settled without admission, matters litigated, and matters finding no wrongdoing.
• DMEPOS supplier standards and enrollment requirements, CMS.
• Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001 et seq. — the statutory basis for self-funded plan governance.
• Exclusion authorities, 42 U.S.C. § 1320a-7; the OIG List of Excluded Individuals and Entities at exclusions.oig.hhs.gov; and the OIG special advisory bulletin on the effect of exclusion.
• False Claims Act, 31 U.S.C. §§ 3729–3733 — including the definition of "knowingly" at § 3729(b)(1), which reaches deliberate ignorance and reckless disregard.
• False Claims Act, 31 U.S.C. §§ 3729–3733 — prohibited conduct at § 3729(a); the definition of "knowingly" at § 3729(b)(1); qui tam and anti-retaliation provisions at § 3730.
• False Claims Act, 31 U.S.C. §§ 3729–3733 — the false-record theory, which is the actual exposure behind §38.3's leading query and §38.9's false positive.
• Families First Coronavirus Response Act of 2020 — the Medicaid continuous enrollment condition.
• Federal regulations governing the confidentiality of substance use disorder patient records, which impose requirements beyond HIPAA including on redisclosure.
• Federal rulemaking on attachment standards, Federal Register. Searching for the current state beats any secondary source, because secondary sources frequently describe a proposal that did not finalize.
• Financial assistance policy obligations applicable to nonprofit hospitals, including limitations on amounts charged to eligible patients.
• Form CMS-10611, Medicare Outpatient Observation Notice, and the Notice of Observation Treatment and Implication for Care Eligibility Act.
• Form CMS-R-131, Advance Beneficiary Notice of Noncoverage, and its instructions.
• FY 2014 Inpatient Prospective Payment System final rule — the two-midnight benchmark — and subsequent rulemaking and sub-regulatory guidance revising it.
• General Equivalence Mappings and CMS's accompanying documentation explaining what a GEM is and is not.
• Geographic Practice Cost Index tables, CMS. Free. Work, practice expense, and malpractice indices by payment locality.
• Good faith estimate requirements under the federal surprise billing framework, for uninsured and self-pay patients.
• HCPCS Level II code set, CMS. Free, downloadable, updated quarterly. Complete codes and descriptors.
• HCPCS Level II quarterly update files, CMS — additions, revisions, and terminations.
• HCPCS Level II quarterly update files, CMS.
• Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted within the American Recovery and Reinvestment Act of 2009 — the statutory basis for electronic health record adoption incentives.
• HHS Office for Civil Rights guidance, enforcement highlights, and published resolution agreements.
• HHS Office for Civil Rights HIPAA guidance.
• HHS Office of Inspector General Work Plan (continuously updated) and the OIG's published audit and evaluation reports.
• HHS Office of Inspector General Work Plan — documentation-driven severity capture, risk-adjustment data validation, and hospital coding patterns; free, public, and a forecast of scrutiny.
• HHS rulemaking establishing and extending the ICD-10 compliance date, and the 2014 statutory delay; final compliance date October 1, 2015.
• HIPAA Administrative Simplification transaction standards, and the ASC X12 implementation guides for the 270/271 eligibility inquiry and response and the 278 services review.
• HIPAA Breach Notification Rule, 45 C.F.R. Part 164 Subpart D, and the HITECH Act provisions underlying it.
• HIPAA Privacy Rule, 45 C.F.R. Part 164 Subpart E — including § 164.502(b) and § 164.514(d) (minimum necessary) and § 164.506 (treatment, payment, and health care operations).
• HIPAA Privacy Rule, 45 C.F.R. § 164.501 (designated record set), § 164.524 (right of access), § 164.526 (right to request amendment) — the basis for §4.8.
• HIPAA Privacy Rule, minimum necessary standard — the basis for §38.3's element 2 (the relevant excerpt only).
• HIPAA Security Rule, 45 C.F.R. Part 164 Subpart C.
• HIPAA Transactions and Code Sets standards, 45 C.F.R. Part 162 — the regulatory basis for ICD-10-CM, CPT, and HCPCS as national code sets.
• Hospital price transparency machine-readable files published by individual hospitals, containing payer-specific negotiated rates.
• Hospital price transparency requirements and CMS implementation guidance — the machine-readable file contents and the shoppable services display.
• Hospital Price Transparency rule, 45 C.F.R. Part 180, and the CMS hospital price transparency resource pages — the subject of Chapter 1, Case Study 1.
• ICD-10 Coordination and Maintenance Committee meeting materials — agendas, proposals, presentations, and public comment summaries from the twice-yearly public meetings.
• ICD-10-CM addenda files, published with each annual update — the authoritative list of additions, deletions, and revisions.
• ICD-10-CM Alphabetic Index and Tabular List files, free from CMS and NCHS.
• ICD-10-CM annual addenda — the record of revisions to the hypertension guidance, the heart failure categories, and the cerebrovascular sequelae categories.
• ICD-10-CM annual Guidelines revisions and addenda — the record of how the "with" convention and others have been narrowed and clarified since 2015.
• ICD-10-CM code files and the ICD-10-CM Official Guidelines for Coding and Reporting, free from CMS and the National Center for Health Statistics, reissued every October 1.
• ICD-10-CM Official Guidelines for Coding and Reporting, Sections II/III and IV — the opposite treatment of uncertain diagnoses in the inpatient and outpatient settings.
• ICD-10-CM Official Guidelines, Section I.C — chapter-specific guidelines. Specifically I.C.1 (infectious and parasitic diseases, including HIV and sepsis), I.C.2 (neoplasms), I.C.3 (blood and blood-forming organs), I.C.4 (endocrine, including diabetes), I.C.5 (mental, behavioral, and neurodevelopmental), and I.C.6 (nervous system, including G89 pain).
• ICD-10-CM Official Guidelines, Section I.C.18 — symptoms, signs, and abnormal clinical and laboratory findings.
• ICD-10-CM Official Guidelines, Section I.C.9 — circulatory system. Contains the hypertension asymmetry, the myocardial infarction time rule, and the cerebrovascular sequelae guidance. The most important reading for this chapter.
• ICD-10-CM Table of Neoplasms, Table of Drugs and Chemicals, and External Cause Index, as published within the code set.
• ICD-10-CM Tabular List and Alphabetic Index files, free and downloadable from CMS and NCHS.
• ICD-10-PCS code files and ICD-10-PCS Official Guidelines, free from CMS.
• ICD-10-PCS code files and Official Guidelines, maintained by CMS.
• ICD-10-PCS code set, ICD-10-PCS Official Guidelines for Coding and Reporting, and the ICD-10-PCS Reference Manual (CMS, free, updated every October 1) — the structural authority behind §33.9, including the root operation definitions.
• Individual Medicare Administrative Contractor websites — LCD indexes, bulletins, and education for each jurisdiction.
• Internal Revenue Service annual revenue procedure on HSA and HDHP limits — minimum deductible, maximum out-of-pocket, and contribution limits, indexed and republished every year. Verify the current year.
• IPPS final rule, annual, Federal Register — for the current transfer DRG list and the geometric mean length of stay values.
• LCD reconsideration processes, as published by each Medicare Administrative Contractor.
• Local coverage determinations and associated policy articles for DMEPOS items.
• Local coverage determinations and their associated billing and coding articles, by jurisdiction. The article contains the CPT/HCPCS codes, the ICD-10-CM codes that support medical necessity, documentation requirements, and utilization expectations.
• MAC provider-facing guidance on institutional billing: type of bill, discharge status, revenue codes, the payment window.
• Medicaid NCCI edit files and Medicaid NCCI Technical Guidance Manual, CMS. Related to but not identical with the Medicare files.
• Medically Unlikely Edit tables, CMS. Free, quarterly, with the MUE Adjudication Indicator. Some values are not published.
• Medicare Administrative Contractor published guidance on cloned documentation — the standard formulation that documentation is cloned when each entry is identical to previous entries and that cloned documentation does not demonstrate the medical necessity of the specific encounter billed.
• Medicare Advantage and Part D program rulemaking on utilization management, contract year 2024 and forward (Federal Register; CMS Medicare Advantage program pages) — internal coverage criteria and their publication, individualized medical necessity determination, prior authorization validity for a course of treatment, and the Utilization Management Committee. Case Study 1's primary source; read the preamble as well as the regulatory text.
• Medicare and Medicaid EHR Incentive Programs, later restructured as Promoting Interoperability.
• Medicare Benefit Policy Manual, CMS Publication 100-02 — what is and is not a Medicare benefit, including statutory exclusions.
• Medicare Claims Processing Manual, Chapter 1 — general billing requirements, including frequency digits and adjustment/cancel claims.
• Medicare Claims Processing Manual, Chapter 3 — inpatient hospital billing. The post-acute care transfer policy and the three-day payment window.
• Medicare Claims Processing Manual, Chapter 4 — Part B hospital and OPPS, for the outpatient HCPCS requirement.
• Medicare Claims Processing Manual, Pub. 100-04, for corrected-claim and adjustment-claim handling (Ch. 1 for professional, Ch. 25 for institutional).
• Medicare Clinical Laboratory Fee Schedule. Free.
• Medicare Coverage Database, CMS — searchable by code, keyword, contractor, or state; contains NCDs, LCDs, and billing and coding articles.
• Medicare Coverage Database, CMS — searchable repository of every national coverage determination, local coverage determination, and billing and coding article. The single most operationally valuable free resource in this book.
• Medicare Coverage Database, CMS. Free, searchable by code, keyword, state, and contractor. Holds NCDs, LCDs, proposed LCDs, and billing and coding articles.
• Medicare Outpatient Observation Notice (MOON) statutory and regulatory requirements — content, timing, and the oral explanation obligation.
• Medicare Part B drug average sales price files, CMS. Free, published quarterly.
• Medicare Physician Fee Schedule Look-Up Tool and the relative value file, CMS.
• Medicare Physician Fee Schedule relative value file, CMS — carries the global period indicator and modifier indicators for each CPT code. Free.
• Medicare Physician Fee Schedule — the reference point most commercial professional contracts are written against.
• Medicare Prescription Drug, Improvement, and Modernization Act of 2003 — created the health savings account and the statutory definition of a high-deductible health plan.
• Medicare Program Integrity Manual — DMEPOS documentation, written order requirements, proof of delivery, and item-specific documentation lists.
• Medicare Program Integrity Manual, Chapter 3, on documentation requests and the conduct of medical review.
• Medicare Program Integrity Manual, CMS Publication 100-08 — the standards medical review contractors apply.
• Medicare Secondary Payer Manual, CMS Publication 100-05, and 42 U.S.C. § 1395y(b) — the primacy rules and the 20- and 100-employee thresholds.
• Medicare Secondary Payer provisions, 42 U.S.C. § 1395y(b), and CMS coordination of benefits guidance.
• Medicare Secondary Payer statute and regulations; Medicare Secondary Payer Manual, CMS Publication 100-05.
• Medicare.gov beneficiary materials, including the annual Medicare & You handbook.
• MS-DRG Definitions Manual (CMS, free) — MDC structure, DRG inclusion logic, OR-procedure designations, CC/MCC exclusion logic.
• National Association of Insurance Commissioners (NAIC) Coordination of Benefits Model Regulation — the source of the birthday rule and the COB ordering rules, adopted in some form by most states.
• National Center for Health Statistics ICD-10-CM pages, CDC — the maintaining body for the diagnosis classification.
• National Correct Coding Initiative Policy Manual, CMS — organized by CPT section and explaining the reasoning behind edits. Free.
• National Correct Coding Initiative procedure-to-procedure edit files, Medically Unlikely Edit tables, and the NCCI Policy Manual, CMS.
• National coverage determinations, individually, with their conditions.
• National Drug Code Directory, U.S. Food and Drug Administration. Free.
• National Uniform Billing Committee (NUBC) — maintains the UB-04 (CMS-1450) and the institutional code sets. The Official UB-04 Data Specifications Manual is a paid publication.
• National Uniform Claim Committee (NUCC), nucc.org — maintains the CMS-1500 and publishes the 1500 Health Insurance Claim Form Reference Instruction Manual, free.
• NCCI Procedure-to-Procedure edit files, CMS. Free, updated quarterly. Contains the 29827/29822 pairing and its modifier indicator.
• NCHS announcement of U07.1, COVID-19, with an April 1, 2020 effective date, and the accompanying interim coding guidance and its revisions.
• No Surprises Act — Consolidated Appropriations Act, 2021, Division BB, Title I, and the implementing regulations jointly issued by the Departments of Health and Human Services, Labor, and the Treasury. The subject of Chapter 1, Case Study 2. Actively litigated; verify current status.
• NUCC 1500 Health Insurance Claim Form Reference Instruction Manual, National Uniform Claim Committee.
• Office of Inspector General audit reports on Medicare Advantage risk adjustment — the documented basis for Case Study 1's account of the enforcement environment, and the clearest available statement of what "supported by the medical record" means in practice.
• Office of Inspector General guidance on charge uniformity, discounts to uninsured patients, and routine waiver of cost-sharing.
• Office of Inspector General guidance on routine waiver of cost-sharing, including the distinction between routine waiver and individualized hardship determination.
• Office of Inspector General reports on electronic health records and fraud vulnerabilities, including work on copy-paste and over-documentation features, hospital audit-log and copy-paste policies, and the concentration of higher-level evaluation and management billing.
• Office of Inspector General reports on hospital observation stays, short inpatient stays, and emergency department facility level distribution.
• Office of Inspector General Work Plan and published reports on evaluation and management services, including level distribution and time-based selection.
• Office of Inspector General Work Plan and reports on Mohs micrographic surgery, wound care and debridement, and global surgery billing.
• Office of Inspector General Work Plan, HHS-OIG, updated monthly; OIG reports on evaluation and management services billed with modifier 25.
• Office of Inspector General, U.S. Department of Health and Human Services, oig.hhs.gov — the Work Plan, compliance program guidance, the List of Excluded Individuals and Entities, and published enforcement actions.
• OIG compliance program guidance (physician practices, hospitals, third-party billing companies, and the consolidated general compliance program guidance) — the seven elements and the auditing-and- monitoring expectation.
• OIG Compliance Program Guidance for individual and small group physician practices; for hospitals; for third-party medical billing companies; and the consolidated General Compliance Program Guidance. Source of the seven elements.
• OIG Self-Disclosure Protocol.
• OIG Work Plan, updated monthly.
• OPPS Addendum B (every HCPCS code with its status indicator and APC), Addendum A (APCs with relative weights and payment rates), and Addendum D1 (the status indicator definitions — the real version of Figure 34.1); plus the addendum published with the same rule listing the inpatient-only procedures. Free, annual, replaced every January.
• Payer companion guides, per payer. §25.9's seventh rejection cause and Case Study 2 are both about this document.
• Payer policies on specimen handling (99000), imaging guidance, the eye codes versus E/M codes, therapy unit methodology, and infusion documentation requirements.
• Payer prior authorization requirements and peer-to-peer review procedures and deadlines.
• Payer provider manuals and published reimbursement policies — the operative source for bilateral reporting conventions, modifier 25 handling, and X{EPSU} acceptance.
• Payer provider manuals — consultation recognition, same-date admission rules, minimum stay requirements for 99234–99236, and critical care time-to-units tables.
• Payer provider manuals — services requiring authorization, plans requiring referrals, payer definitions of precertification and predetermination, submission channels, and turnaround commitments.
• Payer provider manuals, for item-level requirements and for the corrected-claim process (item 22; Ch. 29 §29.6).
• Payer reimbursement policies on: bilateral reporting conventions; the multiple-procedure percentage and depth; anesthesia time increments and rounding rules; physical status unit values; assistant-at-surgery eligibility; and the global obstetric package including its filing deadline.
• Payer requirements for NDC reporting: required format, unit-of-measure qualifiers, and quantity conventions.
• Payer surgical reimbursement policies, particularly on fracture care, casting supplies, and arthroscopic bundling.
• Payer-published clinical editing policies, where they exist.
• Payer-published evaluation and management level-selection review policies.
• Payment Integrity Information Act of 2019 and its predecessors, with OMB implementing guidance — the statutory definition of an improper payment (including underpayments and insufficient documentation) that Case Study 2 reads closely.
• Physician self-referral law (Stark), 42 U.S.C. § 1395nn, and implementing regulations at 42 C.F.R. §§ 411.350–411.389.
• Proposed LCDs and the response-to-comments documents published with final LCDs.
• Provider contracts — obligations to verify eligibility, obtain authorization, and hold the patient harmless when the provider does not.
• Section 340B of the Public Health Service Act — the drug pricing program at the center of Case Study 2, administered by HRSA.
• Section I.A.15 — the "with" convention, read alongside I.C.9 because the interaction between them is the source of most hypertension coding disagreement.
• Section I.C.10 — respiratory system, including respiratory failure sequencing.
• Section I.C.11 — digestive system.
• Section I.C.12 — skin and subcutaneous tissue, carrying the pressure ulcer guidance.
• Section I.C.13 — musculoskeletal system and connective tissue.
• Section I.C.14 — genitourinary system, including chronic kidney disease staging and transplant status.
• Section I.C.15 — pregnancy, childbirth, and the puerperium: priority, trimesters, the fetus character, and outcome of delivery.
• Section I.C.19 — injury, poisoning, and certain other consequences of external causes. The longest and densest subsection in Section I.C: seventh-character definitions, fracture rules, burn rules, and the poisoning / adverse effect / underdosing guidance.
• Section I.C.20 — external causes of morbidity, including the never-first-listed rule and once-per-injury reporting for place, activity, and status.
• Section I.C.21 — factors influencing health status and contact with health services. The Z-code chapter.
• Social Security Act § 1862(a)(1)(A) — the "reasonable and necessary" standard underlying every coverage determination.
• Social Security Act §1128J(d) (the Affordable Care Act's sixty-day overpayment provision) and the CMS regulations implementing it — the identification standard, reasonable diligence, and the lookback period. Revised by rulemaking more than once; verify current text.
• Social Security Act §1833(t) (42 U.S.C. § 1395l(t)) — the OPPS statute, including budget neutrality and the volume-control provision at issue in Case Study 1.
• Social Security Amendments of 1983, Public Law 98-21 — the statute creating IPPS.
• State Medicaid agency provider manuals and fee schedules.
• State statutes governing disclosure of HIV status, which vary and frequently exceed the federal baseline.
• Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) — the cost-limit predecessor discussed in Case Study 1.
• The Affordable Care Act sixty-day overpayment provision, and CMS's implementing rules for Parts C and D (litigated; verify the current state of the law).
• The Affordable Care Act statutory minimum coding intensity adjustment applied to Medicare Advantage risk scores.
• The CMS-HCC model software and its published diagnosis-to-category mappings and coefficient tables — the only correct source for whether a code maps and to what, by model version.
• The HHS-HCC commercial risk adjustment program, documented in the annual Notice of Benefit and Payment Parameters.
• The Integrated Outpatient Code Editor (I/OCE) — CMS's quarterly release files and specifications: the edit list, the dispositions (line item rejection, line item denial, claim returned to provider, suspension), and the status indicator/APC assignment logic behind §34.7.
• The Advance Beneficiary Notice of Noncoverage form (CMS-R-131) and its instructions, CMS. The instructions state the requirements, describe the three options, and address routine and blanket notices explicitly.
• The Affordable Care Act's HAC Reduction Program provisions — the hospital-level quality program distinguished from the claim-level HAC provision in §33.7.
• The annual IPPS final rule (Federal Register) — CC/MCC list revisions and MS-DRG changes; the document a CDI worklist is rebuilt from every October 1.
• The annual IPPS final rule, Federal Register (CMS IPPS rulemaking homepage) — standardized amounts and labor-related shares, wage indexes, all MS-DRG relative weights, GMLOS/AMLOS tables, the outlier fixed-loss threshold, the transfer DRG list, and CC/MCC list revisions.
• The annual OPPS/ASC final rule, Federal Register (CMS Hospital Outpatient PPS rulemaking pages) — the OPPS conversion factor, the labor-related share, every APC relative weight, the drug packaging threshold, status indicator assignments, the comprehensive APC list and complexity adjustments, the inpatient-only list's annual changes, and the ASC conversion factor and covered-procedures list.
• The CMS-1500 form itself, current version, from the NUCC.
• The current Supplemental Medical Review Contractor's project pages (active and completed national review topics).
• The current year's CPT® code book (American Medical Association), specifically the section guidelines and the parenthetical notes for Surgery, Medicine, and Anesthesia. The Anesthesia guidelines define anesthesia time, physical status reporting, and qualifying circumstances. CPT changes every January 1.
• The False Claims Act, 31 U.S.C. §§ 3729–3733, particularly § 3729(b)(1)'s definition of "knowingly."
• The Health Care Provider Taxonomy Code Set, maintained by the NUCC. Free.
• The ICD-10-CM Table of Drugs and Chemicals, as published in the code set.
• The place of service code set and CMS place of service guidance. The telehealth entries have changed repeatedly; verify current policy.
• The Table of Neoplasms and the ICD-10-CM Alphabetic Index, including the morphology entries that govern over the table.
• The three-day payment window as codified in statute, including the "wholly owned or operated" language. Case Study 2's entire failure lives in that clause, and paraphrases consistently drop it.
• The Uniform Hospital Discharge Data Set (UHDDS) definitions — principal and additional diagnosis reporting standards for inpatient claims.
• TRICARE, tricare.mil, and the TRICARE Manuals published by the Defense Health Agency.
• U.S. Department of Labor claims procedure regulation, 29 C.F.R. § 2560.503-1 — timelines and content requirements for benefit determinations and appeals under ERISA plans.
• World Health Organization ICD — the international parent classification that ICD-10-CM modifies, and the body that established the emergency U-codes.
• Your clearinghouse's 835 documentation and field mapping. Provider-level adjustments are the section intermediary reports most often collapse or hide.
• Your own clearinghouse's documentation and portal — the retrieval path for a transmitted 837, the acknowledgment history, the report archive. The single most useful item on this list, and it is behind a login the reader already has.

Tier 2 — Attributed (specifics unverified)

• AAPC and AHIMA specialty resources and credential materials — the study material for a specialty credential is a usable inventory of that specialty's conventions. Chapter 39 §39.3 covers the credential landscape.
• AAPC Certified Risk Adjustment Coder (CRC) materials and AHIMA risk-adjustment practice resources — the professional literature for this specialty. Benchmarks and survey figures are ranges, not facts.
• Choosing Wisely recommendations of the American Geriatrics Society on glycemic targets in older adults, and current professional guidance on individualized targets.
• Clearinghouse edit lists, frequently more specific than payer material — a clearinghouse is paid to prevent rejections rather than explain them (§27.5).
• Code book publishers' current editions and approved-publisher status for examinations. Which editions are acceptable is a candidate-handbook question, not a publisher-marketing question. Ch. 6 §6.1 covers choosing for the desk.
• Coder accuracy standards. ⚠️ No figure is printed anywhere in this chapter or its companion files as an authoritative standard. Chapter 6 §6.9 notes that standards in the mid-to-high nineties are commonly cited and that the crucial question is always what is being measured; Chapter 37 §37.3 establishes that a figure without its denominator is not a standard. The numbers vary by setting, specialty, document type, and employer.
• Coder productivity benchmarks from associations, consultancies, and vendors. Useful as a sanity check, dangerous as a standard: almost none state whether the rate is over chart time or over a working day.
• Coding practice communities and forums. Useful for market orientation and for "which credential do employers here want," which is exactly the question §39.5 answers locally. Not authority on any parameter.
• Continuing education requirements, credential maintenance fees, and specialty credential eligibility — Tier 2 at best from any source other than the issuing organization, and revised.
• Cost-to-collect benchmarks for physician practices — commonly discussed in the low single digits as a percent of collections; varies with specialty, payer mix, and what gets counted.
• Department of Justice press releases and complaints on False Claims Act resolutions involving Medicare Advantage risk adjustment — the primary public record of what has been alleged and resolved. Amounts and case status change; read the source.
• Employer tuition and certification reimbursement policies. Frequently available and rarely advertised; §39.1's "ask before you pay."
• Formal coding programs — community college, technical school, and organization-run. Quality varies and nothing standardizes it; the three screening questions are in the further reading (CAHIIM accreditation if the academic pathway is the goal, whether completion counts toward an experience substitution, and whether timed practice with real documentation is included).
• Gerstein, H. C., et al., "Effects of Intensive Glucose Lowering in Type 2 Diabetes" (the ACCORD trial), New England Journal of Medicine, 2008; with the ADVANCE and VADT reports of the same period. The clinical evidence behind Case Study 2.
• HFMA MAP Keys — standardized revenue cycle metric definitions (days in AR, aged AR, cost to collect). Cited for definitions, not targets; Ch. 1's further reading already flagged that a MAP Key definition may differ from this book's teaching computation.
• HFMA's MAP Keys and comparable standardized revenue-cycle metric definitions. The definitions are the value, not the benchmark values — Chapter 29 §29.7's denominator problem is why.
• HFMA material on denial management, revenue cycle KPIs, and metric standardization. ⚠️ Read it for the DEFINITIONS rather than the benchmarks — §29.7's denominator problem is exactly why that body of work exists.
• HFMA patient-friendly billing and financial communication material — the statement-design and financial-conversation frameworks behind §32.6 and §32.10.
• Job postings within a reader's commuting radius, read with §39.5's four columns. Not usually treated as a source, and for the question §39.5 asks they are the best available one, because the answer is local and nobody publishes it at that resolution.
• KFF research on medical debt — the population-level basis for §32.1's qualitative claims, including that most U.S. medical debt is held by people who were insured; and the annual KFF Employer Health Benefits Survey for the deductible trend. Figures characterized, not quoted.
• MGMA benchmarking data — days in AR, AR over 90, net collection rate by specialty. Quoted only as ranges: "days in AR under 40 commonly targeted, under 35 strong"; "AR over 90 under roughly 15–20%"; "cost to collect in the low single digits as a percent of collections." All carry verify-current-figures language.
• MGMA benchmarking data, with the same caution: a published rate was computed under somebody else's three denominator choices.
• NCQA HEDIS measure specifications and the documentation of whatever measure stewards a contract names — the current version, not last year's.
• New York Times investigation of Providence's collection practices (September 2022) — training-script excerpts and patient accounts; used for the documented pattern, attributed as reporting.
• OIG reports and Work Plan items on Medicare Advantage risk adjustment — contract-level audits of individual organizations and thematic work on diagnoses sourced only from chart reviews or health risk assessments. Searchable at oig.hhs.gov.
• OIG reports and Work Plan items on emergency department facility visit level reporting, cardiac device and procedure coverage, anesthesia time and medical direction, and evaluation and management reported with preventive services — the documented audit landscape behind §35.5, §35.6, and §35.7. Cited as recurring subjects; no figures asserted.
• OIG Work Plan items on discharge status and the post-acute care transfer policy. The documented basis for Case Study 1 being a composite of a known pattern rather than an invention.
• Payer provider bulletins and published medical policies for the plans carrying a practice's volume — where a telehealth policy change, an anesthesia increment or rounding rule, or an obstetric package interpretation appears first. Chapter 6 §6.7's update discipline, made specific.
• Peer-reviewed surprise-billing research (mid-2010s onward) analyzing out-of-network billing at in-network facilities in large commercial claims databases — the commonly cited roughly-one-in-five share of emergency visits, and the staffing-company findings. Case Study 1's evidence base; characterized as ranges.
• Practice management vendor documentation on field-to-segment mapping. Case Study 2 is eleven years of nobody reading it; it is usually available and usually ignored.
• Prevalence of remote, contract, outsourced, and offshore arrangements — genuinely common, poorly measured. Characterize; do not quote a share.
• Published denial-rate and overturn-rate benchmarks from industry surveys and clearinghouse data. Computed under somebody else's three choices; comparing to them compares definitions as much as performance.
• Published practice sets, question banks, and full-length practice examinations. Ch. 8's further reading made the case ("the skill is built by volume") and promised this chapter. Two cautions recorded in §39.7 and the further reading: verify the set is written to the current code sets, and use the error log rather than the practice score.
• Simborg, D., "DRG creep: a new hospital-acquired disease," New England Journal of Medicine (1981). Forty years early, two pages, and the clearest short statement of the general problem this chapter's enforcement landscape manages.
• Specialty society coding resources — the American College of Cardiology, the American Academy of Orthopaedic Surgeons, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Society of Anesthesiologists. Authoritative readings of the code set, written by people who do the work, and advocacy for their members' interests; where a society's reading conflicts with a payer's published policy, the payer's policy governs the claim.
• The 2019 nonprofit hospital collections investigations — the MLK50/ProPublica reporting on a Memphis health system's patient lawsuits and the Kaiser Health News (now KFF Health News) reporting on a Virginia university health system — and the documented reversals that followed. Case Study 2's record; all figures characterized ("thousands," "tens of thousands"), never asserted precisely.
• The Bureau of Labor Statistics occupational profile covering this work. The occupational category has been renamed over the years, so the current title must be searched; the state and metropolitan-area tables carry the variance and the national figure carries little of what a reader needs. No figure quoted anywhere in this chapter.
• The credentialing organizations' member salary surveys. Attributed and structurally limited: self-reported and member-only, therefore a self-selected population rather than a workforce estimate. §39.5 says so explicitly and prints no figure.
• The nationwide credit bureaus' 2022–2023 medical-debt reporting changes (paid collections removed; small balances unreported; extended waiting period) and subsequent contested federal rulemaking — stated as a moving landscape, verify current.
• The professional coding press — useful for noticing that a section has been restructured; never the authority for what the restructuring says.
• The reader's own payer participation agreements and provider manuals — record-request rights, lookback, recoupment and offset terms, reconsideration windows, whether extrapolation is authorized, and the amendment mechanism. Tier 2 because it varies entirely by contract, and the single most important item on this list for a practice whose commercial book exceeds its Medicare book.
• WEDI material on transaction adoption and implementation issues; the organization exists specifically to work on these transactions.
• AAPC and AHIMA audit and compliance material, including the Certified Professional Medical Auditor (CPMA) curriculum outline.
• AAPC and AHIMA codes of ethics and standards of ethical coding — the basis for §5.10.
• AAPC and AHIMA E/M training material and audit worksheets. Check publication date before use.
• AAPC and AHIMA educational material on CPT structure, symbols, and the semicolon convention. Useful as a second explanation, particularly for the add-on versus modifier-51-exempt distinction.
• AAPC and AHIMA educational material on hypertension coding — the most-written-about convention in diagnosis coding. Check the publication date; older material describes superseded versions of the guidance.
• AAPC and AHIMA educational material on ICD-10-CM conventions — useful as a second explanation; the Guidelines are the authority.
• AAPC and AHIMA educational material on index and tabular navigation, main term selection, the Excludes notes, and the specialty tables. Useful as a second explanation; the Guidelines are the authority.
• AAPC and AHIMA educational material on modifier application, the 25/57 distinction, and the global-period set.
• AAPC and AHIMA educational material on neoplasm coding and diabetes coding.
• AAPC and AHIMA educational material on the seventh character, on Z-codes, and on the Table of Drugs and Chemicals.
• AAPC and AHIMA material on claim form completion, including practice claim-building exercises.
• AAPC and AHIMA material on denial management, appeals workflow, and root-cause analysis.
• AAPC and AHIMA material on HCPCS Level II, particularly units and the JW/JZ distinction.
• AAPC and AHIMA material on medical necessity, LCDs, and ABNs.
• AAPC and AHIMA material on NCCI edits and modifier 59.
• AAPC and AHIMA material on payment posting and denial identification.
• AAPC and AHIMA published rules on code books permitted in credentialing examinations. These differ between organizations and change; verify directly with the administering organization.
• AAPC and AHIMA surgical coding material, including guidance on reading operative reports.
• AAPC Certified Outpatient Coder (COC) preparation materials and AHIMA facility coding resources — the practice sets that make status indicators automatic. Benchmarks and pass-rate figures in this literature are ranges, not facts.
• AAPC, aapc.com — credentialing body (CPC, COC, CIC, CPB, CRC, CPMA), substantial free educational material, local chapters.
• AAPC, AHIMA, and HFMA material on EDI operations, clearinghouse selection, and revenue cycle technology.
• ACDIS (Association of Clinical Documentation Integrity Specialists) materials on query practice, concurrent review, and program design. Some material members-only.
• ACDIS practice literature and annual industry surveys on CDI structure, staffing, query rate, response rate, and metrics. Useful for structure, never as a benchmark: Chapter 29 §29.7's denominator problem applies to every figure in it.
• AHIMA and AAPC guidance and commentary on guideline application, particularly on the "with" convention as it was revised. Useful for understanding why practitioners found it ambiguous; the Guidelines are the authority.
• AHIMA and AAPC material on facility coding, the inpatient/outpatient distinction, and chargemaster maintenance.
• AHIMA and ACDIS practice literature on clinical documentation integrity, compliant query practice, and CMI analysis — bridge material to Chapter 38; benchmarks are ranges, not facts.
• AHIMA's published evaluation work on computer-assisted coding, including the peer-reviewed studies of CAC's effect on coder productivity and accuracy published as the technology entered wide use. The durable finding is directional — assisted coders outperform both unassisted coders and the engine alone — and it is the honest case for §38.8's workflow. Every specific percentage is a measurement of one product on one chart population; cited qualitatively only.
• American College of Obstetricians and Gynecologists coding resources and obstetric coding material generally.
• American Health Information Management Association (AHIMA), ahima.org — credentialing body (CCS, CCS-P, CCA, RHIT, RHIA, CDIP).
• American Medical Association implementation guides and educational material on the 2021 and 2023 E/M changes.
• Analyses of hospital price transparency compliance and machine-readable file quality.
• Anesthesia billing specialty literature, particularly on payer variation in time increments and rounding.
• Cardiology and nephrology specialty society coding guidance on documentation specificity.
• Case management and utilization review professional literature on status determination and observation stay management.
• Case-based practice sets and workbooks pairing scenarios with guideline citations.
• Charge capture literature, including reconciliation methodologies.
• Chargemaster management literature and guidance on charge description master review cycles.
• Circulating benchmarks for audit sample sizes and coder accuracy standards — orientation only, and never comparable across organizations without the denominator stated.
• Clearinghouse documentation and published edit lists — frequently more specific than payer material, because a clearinghouse is trying to prevent rejections rather than explain them.
• Clinical documentation integrity literature on sepsis querying.
• CMS educational articles and Medicare Administrative Contractor local billing guidance on outpatient facility claims — the closest thing to a rulebook for what CMS deliberately left local, including facility E/M leveling expectations, for which there are no national criteria.
• CMS published Medicaid unwinding data — state-reported monthly disenrollment counts and procedural termination rates.
• CMS's published announcements of the Recovery Audit Program's next-round operating changes: ADR limits scaled to provider compliance, the discussion period, contingency fees withheld until after the second level of appeal, accuracy and overturn thresholds, and the shortened patient-status lookback. The specific parameters change by contract; verify.
• Code book publisher navigation aids — color coding, symbols, and margin indicators for Excludes notes, seventh-character requirements, and codes needing additional characters. Publisher conventions, not part of the code set; two publishers may mark the same thing differently and neither marking is authoritative.
• Code book publisher supplementary material — coding tips, illustrations, and cross-references added by publishers. Publisher content, not CPT; helpful and not authoritative.
• Code book publishers' annual summary-of-changes documents, and the CMS ICD-10-CM addenda files.
• Coding association and specialty society material on principal diagnosis selection with worked admissions.
• Coding forums and practice communities — genuinely useful for "which main term," which is hard to answer from a reference and easy to answer from someone who does it daily. Follow every answer to the index before relying on it.
• Coding productivity and quality benchmark publications from professional associations and consultancies. Orientation only; ask whether accuracy is measured per chart or per code.
• Collectability decay with age — stated qualitatively/in ranges only ("a balance pursued in the first 30–60 days collects at a multiple of the rate after 120"; agency recoveries "a minority of face value"; contingency fees "commonly a third or so"). No precise decay curve is quoted anywhere in the chapter, deliberately.
• Commentary on autoposting configuration and exception queue management.
• Commentary on CPT governance, including on the Editorial Panel's composition and the RUC's role in valuation. A genuinely contested policy area with substantial argument on both sides.
• Commentary on documentation burden and clinician burnout as the stated motivation for the 2021 revision.
• Commentary on interim billing and the sequencing rules for frequency 2/3/4 claims.
• Commentary on real-time adjudication pilots and where they currently work.
• Commentary on the annual conversion factor debate and budget neutrality.
• Commentary on the transition from paper to electronic submission.
• Commercial encoder and code book publisher reference material on conventions, placeholders, and seventh characters.
• Comparative analyses of modifier 59 utilization in surgical specialties.
• Compliance guidance on ABN processes, including the routine-ABN problem.
• Compliance guidance on charge description master and facility leveling criteria maintenance and review cycles.
• Compliance guidance on point-of-service collection scripting.
• Compliance literature on automated modifier application and claim scrubber configuration.
• Compliance literature on automatic modifier application in billing systems and claim scrubbers.
• Compliance literature on billing macros and automated modifier application.
• Compliance literature on claim line sequencing and practice management system configuration.
• Compliance literature on electronic health record template design and default values.
• Compliance material on charge master maintenance for supply and drug lines.
• Compliance material on standing orders and recurring order review.
• Compliance program design resources from healthcare compliance professional organizations, including sample policies, risk assessment methodologies, and audit workplan templates scaled by organization size.
• Congressional oversight material on Medicare Advantage prior authorization in post-acute care, including published committee investigation reports. Case Study 1's context; no figure from this material is asserted in this book.
• Consumer and journalistic reporting on observation status and skilled nursing facility coverage denials.
• Contract management and underpayment recovery vendor material. Read skeptically and read it anyway — these vendors have solved step 1 at scale.
• Credit bureau treatment of medical debt (paid and small-balance medical collections removed; reporting delays; further federal rulemaking in motion and litigated) — described directionally with verify-current-status language.
• Electronic health record vendor documentation on provenance tagging, copy-forward indicators, and audit-log contents.
• Emergency medicine professional society coding resources.
• Encoder, practice management system, and clearinghouse vendor documentation on logic pathways, edit configuration, and update scheduling.
• Escheat / state unclaimed-property obligations for unrefundable patient credits — mentioned, state-specific, verify.
• FY 2014 inpatient prospective payment system final rule and subsequent CMS guidance on the two-midnight benchmark; the transfer of short-stay medical review to probe-and-educate and subsequently to the Beneficiary and Family Centered Care Quality Improvement Organizations.
• Gastroenterology society guidance on the screening-to-diagnostic colonoscopy problem.
• Government Accountability Office reports on Medicare program integrity, the Recovery Audit program, and improper payment estimation — including GAO's statements that improper payments and fraud are distinct concepts requiring distinct measurement.
• Health care fraud enforcement commentary, including analyses of qui tam trends.
• Health services and biomedical informatics literature measuring copy-paste and imported text in electronic clinical notes. The direction of the finding is well established; specific proportions vary by study, setting, and method and should be cited from the study.
• Health services research and contemporaneous business reporting on the 1990s managed care and capitation expansion, its failure modes, and the physician group insolvencies that followed — the documented basis for Case Study 2.
• Health services research on observation status growth and its consequences for skilled nursing facility eligibility. Mechanism well documented; magnitudes vary by study and period.
• Health services research on sepsis incidence and its relationship to coding and documentation practice. Disentangling incidence from coding is an active and difficult question; any trend figure should be read with its methodology.
• Health services research on the ICD-10 transition's effects on data comparability, coder productivity, and coding accuracy.
• Healthcare Financial Management Association (HFMA) materials on payer contract management and payment model design.
• Healthcare Financial Management Association (HFMA), hfma.org — the MAP Keys are the most widely used standard definitions of revenue cycle metrics. Some material members-only.
• Healthcare financial management literature on front-end revenue cycle metrics and published benchmarks.
• Healthcare fraud enforcement analysis in professional association materials, law firm client alerts, and trade press. Useful for patterns; verify specifics against underlying settlement documents and court filings, which are generally public.
• HFMA / MGMA / AAPC / AHIMA material on appeals workflow, appeal letters, and tracking.
• HFMA material on revenue integrity, contract modeling, and net revenue measurement.
• Hospital association and health-system policy analyses of site-neutral payment, read alongside the critiques — the differential's rationale (standby capacity, EMTALA obligations, acuity mix) and its critique (site-shifting and acquisition incentives) are both real and both documented.
• Hospital medicine society material on inpatient E/M coding, concurrent care, and hospital documentation.
• Industry estimates that NSA protections applied to millions of claims in the law's first months — characterized, not quoted.
• Infusion and oncology pharmacy literature on vial size, waste, and dose rounding.
• International consensus definitions of sepsis, including the SIRS-based framework and the later definition commonly called Sepsis-3, published in the medical literature. The basis of Case Study 1.
• Investigative reporting on hospital billing and medical debt (KFF Health News and comparable outlets) — read for documented mechanisms, follow the primary sources.
• Journalistic and academic work on chargemaster prices and the uninsured.
• Kaiser Family Foundation (KFF) and the Peterson-KFF Health System Tracker — independent analysis of coverage, cost, medical debt, and surprise billing, with published methodology.
• Kaiser Family Foundation Employer Health Benefits Survey, published annually — the standard reference for high-deductible plan enrollment, average deductible amounts, premium contributions, and plan-type distribution. Figures change every year; methodology published.
• Kaiser Family Foundation Medicare and Medicaid tracking — enrollment figures, Medicare Advantage penetration, and state-level Medicaid unwinding data.
• Literature on documentation burden and note length, including comparative work on American clinical note length. Phenomenon well documented; treat specific multipliers as study-specific.
• Litigation history of the two-midnight rule payment reduction and of beneficiary appeal rights for inpatient-to-observation reclassification.
• Material on claim scrubber configuration and item-level pre-submission checks.
• Material on EHR template design and structured documentation, including the distinction between prompts and defaults. Ch. 4's copy-forward literature is the closest published analogue to Case Study 2.
• Material on the RVU update process, including specialty society survey methodology and how multispecialty committee recommendations are developed and transmitted to CMS.
• Medical identity theft literature, including consumer protection agency and health information management material on chart contamination.
• Medicare Advantage (Part C) appeal mechanics, including auto-forwarding of upheld plan-level appeals to the independent review entity — verify current procedures.
• Medicare Payment Advisory Commission (MedPAC) reports to Congress — independent analysis of Medicare payment systems, observation stays, Medicare Advantage payment, and physician payment adequacy.
• MedPAC reports to Congress on site-neutral payment, including analysis of the effect of provider-based conversion on beneficiary cost sharing. The national version of §26.9's arithmetic.
• MedPAC, Report to the Congress: Medicare Payment Policy (annual) — hospital payment adequacy, case-mix analysis, and documentation-and-coding effect discussions, including the post-2008 MS-DRG transition experience and the American Taxpayer Relief Act of 2012 recoupments; magnitudes belong to these reports, not to this book.
• New Jersey's DRG-based hospital rate-setting experiment (late 1970s–1980s) — the state pilot preceding national adoption, discussed qualitatively in Case Study 1.
• Obstetric coding material on unbundling the global package, including visit-count divisions and transfer-of-care scenarios.
• Office of Inspector General reports on Medicare Advantage risk-adjustment practices.
• OIG reports and Work Plan items on hospital outpatient billing — provider-based status compliance, outpatient packaging and unbundling, observation and status-change practices, and services billed during a three-day payment window. Cited as a documented and recurring audit landscape; no figures asserted.
• OIG Work Plan items and reports on inpatient hospital billing: severity/MCC capture patterns, POA indicator accuracy, and post-acute transfer discharge-status coding — the audit landscape behind §33.7, §33.8, and both case studies; cited as a documented pattern, no figures asserted.
• OIG Work Plan, updated monthly.
• Oncology and infusion nursing literature on medication administration documentation.
• Ophthalmology society guidance on choosing between the eye codes and the E/M codes.
• Pathology and laboratory professional society material on specimen counting in surgical pathology and on microbiology units.
• Patient access professional association material and certification programs.
• Patient advocacy and journalistic reporting on unexpected preventive-care bills — a useful corrective to treating the screening/diagnostic determination as purely technical.
• Patient advocacy material on advance beneficiary notices and observation notices.
• Payer-published preventive services coding policies, including modifier requirements, which differ by payer.
• Peterson-KFF Health System Tracker — analysis of cost sharing, medical debt, and price variation between providers in the same market.
• Physical therapy and rehabilitation professional association material on the substantial-portion methodology.
• Physician compensation literature on work RVUs as a productivity measure.
• Physician organization commentary and responses regarding payer modifier 25 reduction policies.
• Policy commentary on the qui tam mechanism, both supportive and critical — the basis for Case Study 1's balanced treatment.
• Practice management literature on in-office dispensing: the business case, compliance overhead, and break-even analysis.
• Practice management literature on scheduling and pre-visit workflow.
• Practice management system vendor documentation on claim mapping — how system fields become 837P segments. Case Study 1 is a mapping problem.
• Practice sets and workbooks organized by CPT section.
• Price estimation and patient financial engagement research on estimate accuracy, collection, and satisfaction.
• Professional coding association guidance on the coder's scope and on permissible inference — stated in many places, codified in none.
• Professional coding forums and communities — useful for orientation and for locating the right primary source; not authority.
• Publicly filed class action complaints alleging algorithmic drivers of post-acute coverage terminations by Medicare Advantage organizations — allegations, not findings, and identified as such wherever mentioned.
• Published accounts of the 4010→5010 transition and of subsequent version work.
• Published analyses of denial causes by category. Specific percentages vary by study, setting, and classification method — which is itself Ch. 29 §29.4's point.
• Published analyses of DMEPOS improper payment rates and their causes.
• Published analyses of drug testing utilization and related enforcement actions.
• Published analyses of hospital price-transparency compliance rates (governmental, academic, and journalistic) — characterized as "widespread early shortfalls," no percentage asserted.
• Published analyses of modifier 59 utilization rates across providers and specialties.
• Published analyses of modifier utilization rates across providers and specialties.
• Published analyses of national E/M level distribution before and after 2021.
• Published analyses of national emergency department facility level distribution and its shift over the past decade.
• Published analyses of prior authorization denial and overturn rates.
• Published analyses of the ICD-10 transition, including health services research on coder productivity effects and on the prevalence of unspecified code use after the transition.
• Published analyses of unspecified code use following the ICD-10 transition, from CMS, payers, professional associations, and the health services literature. Pattern consistently reported; magnitudes vary widely by specialty, setting, category, and study definition.
• Published coding practice sets and workbooks — the skill in this chapter is built by volume.
• Published compliance commentary on risk-adjustment coding, from compliance professionals, law firms, and professional associations. Verify specifics against underlying OIG reports, settlements, or filings, which are generally public.
• Published educational guidance on the lesion excision measurement rule.
• Published guidance on chargemaster review and revenue-integrity practice — the discipline §26.5's crosswalk failures belong to.
• Published guidance on claim scrubber configuration and rule libraries.
• Published guidance on hernia repair coding.
• Published guidance on incident-to billing and the rendering provider field.
• Published guidance on write-off taxonomy and on separating charity care from bad debt for reporting purposes.
• Published industry benchmarks for initial denial rate, first-pass resolution rate, days in accounts receivable, and cost to collect — orientation only; denominators and populations differ enormously and vendors have an interest in the direction of the figure. Measure your own.
• Radiology society coding resources, particularly on the professional/technical split, contrast, and ultrasound completeness requirements.
• RAND Corporation evaluations of the Prospective Payment System's effects on quality of care (late 1980s–1990) — the documented basis for the "quality broadly held; unstable discharges rose" summary; cited qualitatively.
• Reported reversal-rate experience at the ALJ level during the RAC era — characterized qualitatively; no precise rate quoted.
• Reporting on the surprise-billing legislative fight, including the advertising campaign later reported to be funded largely by physician-staffing companies; and on IDR volumes far exceeding projections and the repeated vacatur of portions of the implementing rules in federal litigation (the Texas provider-litigation line of cases).
• Research literature on exception reporting in the United Kingdom's Quality and Outcomes Framework — one of the few places the behavior in Case Study 2 has been measured at national scale.
• Revenue cycle benchmarking publications reporting collection rates, days in accounts receivable, and denial rates.
• Risk-adjustment coding guidance from professional organizations on recapture processes and the handling of history codes — the documented context for Case Study 2.
• Risk-adjustment literature on condition specificity, particularly heart failure and chronic kidney disease.
• Senate Finance Committee oversight of nonprofit hospital §501(r) compliance.
• Simborg, D. W., "DRG creep: a new hospital-acquired disease," New England Journal of Medicine (1981) — the coining of Case Study 2's term, published before national implementation.
• Specialty society coding guidance from oncology, endocrinology, infectious disease, and pain medicine organizations.
• Specialty society coding guidance on main term selection for the conditions a given clinical area sees most.
• Specialty society coding guidance on modifiers, particularly surgical specialty material on global-period modifiers.
• Specialty society coding guidance on the categories a given clinical area uses most and the documentation specificity they require.
• Specialty society coding guidance. For CPT more than for ICD-10-CM, specialty societies are the most practical source — they participate in the Editorial Panel process and frequently explain why a code family is structured as it is.
• Specialty society coding resources: gastroenterology, cardiology, urology, obstetrics and gynecology, neurosurgery, anesthesiology.
• Specialty society coding resources: orthopedics, dermatology, plastic surgery, general surgery. Particularly strong on fracture care and arthroscopy.
• Specialty society guidance on coverage policies, including society participation in comment periods and reconsiderations.
• Specialty society guidance on drug billing — oncology, rheumatology, ophthalmology, allergy and immunology.
• Specialty society guidance on edits affecting specific code ranges — orthopedics, gastroenterology, interventional pain management.
• Specialty society guidance on evaluation and management coding within specific specialties.
• Specialty society guidance on injury coding, particularly from orthopedic and emergency medicine organizations.
• State department of insurance consumer guides and provider bulletins — plan types, network adequacy, prompt payment, and external review rights, with the critical caveat that most do not reach self-funded plans.
• State external cause code reporting requirements, which vary and some of which are mandatory. State health departments are the source.
• State external review processes and their scope at the margins; state insurance department complaint procedures for insured plans.
• State law regulating payer audits and extrapolation (notice requirements, lookback limits, constraints on extrapolation). Jurisdictional; a question for counsel.
• State prompt-pay statutes (existence, interest remedies, insurance-department enforcement) — state-specific; ERISA self-funded carve-out noted per Ch. 2 §2.5.
• State workers' compensation agency fee schedules, provider manuals, and required forms — variation between states is enormous and this chapter deliberately did not summarize it.
• The clinical natural language processing literature on negation detection, assertion classification, temporality, and section segmentation in clinical text — cited for the existence and names of the problems in §38.6, not for any performance figure.
• The Yale DRG development literature (Robert Fetter, John Thompson, and colleagues) — the original classification research behind Case Study 1.
• Trade and professional coverage of autonomous coding deployments in radiology, pathology, and screening — read with §38.7's four properties and the denominator question: a "direct autonomous coding rate" is a share of charts within a scoped domain, not a share of a facility's work.
• Trauma registry data standards, which frequently drive external cause data collection independently of billing requirements.
• Typical commercial appeal structures (one or two internal levels; level-one windows commonly 60–180 days from the determination) — contract- and payer-specific; the participation agreement and provider manual govern.
• Utilization management and prior authorization literature, including the policy debate about administrative burden.
• Vendor and clearinghouse documentation on 837I mapping and institutional edits.
• Whistleblower protection material.
• Wound care and debridement coding literature, particularly on depth versus exposure.

Tier 3 — Illustrative / constructed (labeled in text)

• Account 10-4471 (Northgate Family Medicine; Northfield Mutual) — the statement figures (\$47.58 / \$30.00 / \$17.58, days 70 and 100), the two-stage estimate (\$30.60 + \$16.98), and the pre-service estimate document in §32.2's figure.
• Account 10-4471 and every figure in the Encounter checkpoint: \$367.00 charged, \$216.28 allowed, \$150.72 contractual, \$47.58 patient, \$168.70 plan; CO-45 \$56.60 and CO-97 \$128.40 on line 1. Constructed throughout, per the book's anchor files.
• Account 10-4471 — the Encounter; Northgate Family Medicine and Northfield Mutual Health Plan (both constructed). The March 14 office note is Figure 4.2 in Chapter 4 §4.10.
• Account 10-4471 — the March 14 office note, its problem list, its assessment, and the MEAT grid in Figure 36.3. Constructed and canonical within this book; unchanged by this chapter.
• Account 10-4471, Northgate Family Medicine, Northfield Mutual Health Plan — constructed throughout the book.
• Account 22-9107 — the screening colonoscopy; the \$153.00 vs. \$204.00 coinsurance figures at an illustrative 15% phase-down percentage [constructed — verify the current percentage].
• Account 31-2245 — the unbundled shoulder claim; Ridgeview Orthopedic Surgery (constructed). Three lines; the modifier-59 macro; 42 claims over 18 months; \$612.40 average overpayment; \$25,720.80 demanded; 11 defensible and unprovable (\$6,736.40, which would have left \$18,984.40). Introduced Ch. 5, coded Ch. 17 §17.9, run edit-by-edit Ch. 21 §21.9, extrapolated in §37.6.
• Accounts 22-7788 / 10-7789 — the ED bill (\$3,842.00 / \$1,196.40 / \$439.28 / \$63.72 / \$503.00) and §32.10's conversation.
• Case Study 2's individual situations — a clearly labeled composite assembled from documented patterns; no named person, employer, or organization, and no fabricated pass rate, placement rate, salary, fee, or survey result.
• Case Study 2's organization — a labeled composite assembled from documented patterns in the pay-for-performance literature. The clinical evidence and guideline history in that case study are real; the practice is not.
• Every coefficient, benchmark, risk score, panel count, and dollar figure in this chapter — the 1.555 / 1.231 / 0.752 / 0.428 worksheets, the \$1,000.00 PMPM benchmark, the \$18,660.00 and \$3,888.00 and \$97,200.00 figures, the shared-savings settlement, and Northgate's 470-member Medicare Advantage panel. Constructed teaching figures, labeled where they appear, checked against themselves and against nothing in the world.
• Figure 30.1 — the level-one appeal letter for Account 10-4471, and Northfield's provider-manual terms (180-day filing window, 45-day response commitment). All dates reconcile to §6.2's frozen calendar; 59 − 17 = 42 days matches Ch. 21 §21.9's "forty-two days later."
• Figure 30.2 — the constructed Medicare Redetermination Notice (partially favorable).
• Figure 30.3 — the constructed appeal-log export (31 open; 9 with no follow-up date; 6 past the payer deadline; 3 favorable-unposted; 4 with no level recorded).
• Figure 35.1 — constructed cardiac catheterization report (hospital laboratory, group owning no equipment there), used for the two-axis code selection and the component question.
• Figure 35.2 — two constructed orthopedic office-note plan sections, distal radius fractures, illustrating the two sides of the fracture-care fork.
• Figure 35.3 — constructed ED facility acuity criteria sheet (intervention-point model, ten line items, five level bands) and one constructed nursing record scored against it to 17 points → 99284. No real hospital's criteria are reproduced anywhere in this book.
• Figure 36.1's recapture worklist and Figure 36.2's compliance summary — constructed documents built to show what a defensible program's paperwork looks like.
• FIGURE 39.1, "The posting" — a constructed job posting; not a real posting from any employer.
• FIGURE 39.2, "The verification letter" — a constructed letter; not a template approved by any credentialing organization. The organization's current requirements govern its contents.
• Figures 37.1–37.4 — the one-page audit plan; the scoring sheet; a payer's sampling methodology page; two paragraphs of an audit response letter. All constructed.
• Northgate's monthly denial log in §29.7's 🧮 — 4,180 lines adjudicated, 267 denied (6.4%), the nine-row root-cause breakdown summing to 267, 185 preventable (69.3%), and 84 appeals decided with 57 upheld = 68%. ⚠️ The 68% is §8 canon and Chapter 40 uses it. All arithmetic verified.
• The \$102.00 fix, the §40.6 coding-day queue model, and every minute figure in it — constructed to show a structure.
• The constructed conversations — the screening call (§39.1) and the accommodations call (§39.9).
• The ED anchor, Accounts 22-7788 (facility) and 10-7789 (professional) — reused at their frozen figures; both claims carry 99284.
• The Encounter counterfactual — Account 10-4471's patient referred to an orthopedic practice on March 14. A lens; the canonical file is unchanged and the checkpoint deliberately prices nothing.
• The four capstone inputs: 58 minutes across three touches; \$36.00/hour fully loaded (\$0.60 per minute); \$128.40 allowed on the denied line; a 68% overturn rate from 57 of 84 appeals decided. And therefore **\$34.80, \$93.60, and \$51.18** — arithmetically exact given the inputs, and none of them a benchmark.
• The fully loaded rate: \$36.00/hour = \$0.60/minute (§31.7). ⚠️ §8 canon — one of Chapter 40's four sealed inputs, published here by design. Labeled constructed; the chapter tells readers to derive their own from payroll and overhead. Ch. 31 states the rate and the 58 minutes separately and never multiplies.
• The illustrative exam specifications in §39.9 — 100 items / 240 minutes and 115 items / 240 minutes. ⚠️ Not any organization's current parameters and labeled as such in the text; present solely so the arithmetic can be shown.
• The obstetric episode log (§35.4) and the specialty grid (§35.10) — schematic artifacts offered as designs to copy.
• The twelve-week preparation plan (§39.7) and its study-hours arithmetic — constructed planning figures (5 × 90 min + 3 h = 10.5 h/week; × 12 = 126 h; + 2 × (4 + 2) = 12 h; total 138 h; ÷ 5 h/week ≈ 28 weeks). The method transfers; the numbers are the reader's to replace.
• The two 📞 On the Phone conversations — constructed, written close to real ones. No named person appears; the participants are roles.
• The §35.5 🔢 Code It — constructed 9-year-old established-patient well-child note with a separately documented acute otitis media and one nurse-administered influenza vaccine.
• The §35.5 vaccine arithmetic — 1,200 doses, constructed \$26.40 administration allowed amount, 9% capture gap → **\$2,851.20**. Constructed.
• The §35.7 anesthesia arithmetic — 8 base units, P2, anesthesia time 07:46–09:24 (98 minutes) against room time 07:42–09:28 (106 minutes), at Chapter 18 §18.11's constructed conversion factor of \$22.00**: 14 units = **\$308.00; the room-time error and the round-to-nearest alternative both = \$330.00. All constructed.
• The §37.6 counterfactual universe — 380 claims, a 42-claim sample, constructed standard deviations of \$286.00 and \$52.00, a 90 percent two-sided multiplier of ~1.683: point estimate \$232,712.00, demand \$204,489.40, consistency variant \$227,582.00, difference \$23,092.60.
• §29.10's three touches: 14 + 31 + 13 = 58 minutes. ⚠️ §8 canon. Chapter 29 publishes the minutes; Chapter 31 publishes the loaded rate; Chapter 40 assembles them. This chapter must not multiply.
• §37.2's internal-audit yield arithmetic — 214 claims, \$62.40 per claim, identified \$13,353.60, recoverable \$6,052.80, not recoverable \$7,300.80, prospective \$13,353.60/year. Constructed; modeled on Chapter 14's Case Study 2.
• §37.4's prepayment cash arithmetic — \$26,400.00 monthly allowed, 17 → 62 day cycle, \$39,600.00 additional receivable, 12% documentation error rate, 60 ADRs/month at 40–90 minutes each. Constructed.
• 0DTJ4ZZ — the classic laparoscopic appendectomy example, used structurally.
• Account 10-4471 and the March 14 office note (Chapter 4 §4.10, Figure 4.2) — constructed; the source of §38.1's documented negatives, Figure 38.1's two query drafts, and the Encounter's engine output panel. Codes, pointers, charges, and allowed amounts exactly as the book's canon has them.
• Account 10-4471 figures (constructed; the account is built across the book from Chapter 1's Encounter section and Chapter 4 §4.10's note): day-17 posting arithmetic (145.98 = 128.40 + 17.58), the 49 days (day 17 → day 66), bucket traversal, day-70 statement, day-100 payment.
• Account 10-4471 — the Encounter, the constructed progressive project running through all forty chapters.
• Account 10-4471's 20610 package analysis in §17.2 and §17.7.
• Account 10-4471's absence analysis and the Exercise 12.51 counterfactual.
• Account 10-4471's check-in reconstruction in §24.11.
• Account 10-4471's circulatory analysis and the Exercise 11.45 counterfactual.
• Account 10-4471's CPT code locations.
• Account 10-4471's diagnosis analysis, including the two-question resolution of the diabetes line.
• Account 10-4471's J1030 analysis in §20.4, including the JZ conclusion.
• Account 10-4471's laboratory analysis in §19.12, including the in-house counterfactual and its cost arithmetic.
• Account 10-4471's leveling in §15.13.
• Account 10-4471's location diagram in the Encounter checkpoint. The account is constructed; the code and its position in the classification are real.
• Account 10-4471's modifier analysis and the Question 1 resolution.
• Account 10-4471's Q3 and Q5 resolutions, including the constructed post-March-14 imaging supporting M17.11.
• Account 22-7788 — the emergency department facility claim from Chapter 1 (constructed): charges \$3,842.00, allowed \$1,196.40, the \$318.00 supply line and \$96.00 pharmacy line allowed \$0.00 as packaged, patient \$439.28, plan \$757.12. Reproduced here as Figure 34.2 and in the exercises.
• Account 22-8891 — Ridgeview Regional Medical Center's four-day COPD admission (constructed): all diagnoses per the book's frozen canon; DRG 190/191/192 arithmetic at base rate \$6,200.00 with weights 1.1015/0.8003/0.6555; the \$1,867.44 and \$897.76 tier differences; the day-2 L89.153 with POA = N.
• Account 22-9107 — Ridgeview Regional Medical Center's screening colonoscopy that became diagnostic (constructed): the illustrative level 4 GI endoscopy comprehensive APC rate of \$1,020.00, the illustrative 15% phase-down step and the resulting \$153.00 against the 20% figure of \$204.00, and the constructed facility claim of Figure 34.4.
• Account 31-2245 and Case Study 1 in their entirety — Ridgeview Orthopedic Surgery, the 42 claims, the \$612.40 average, the \$25,720.80 demand, and the eleven defensible claims. All constructed. The pattern is one of the most frequently documented findings in surgical coding.
• Account 31-2245's edit walkthrough in §21.9 and Account 10-4471's in the Encounter checkpoint.
• Accounts 22-7788 and 10-7789 — the constructed emergency department bill: charges \$4,522.00, allowed \$1,515.00, patient \$503.00, plan \$1,012.00.
• All clinical scenarios in this chapter: the five worked charts in §11.10, all exercise vignettes, and the diagrams in §11.1, §11.4, and §11.8. Conventions are real; clinical situations are constructed.
• All clinical scenarios in this chapter: the four sepsis scenarios (§10.3), the four diabetes scenarios (§10.6), the five worked charts (§10.10), and all exercise vignettes. Codes are real; clinical situations are constructed.
• All examples in §22.1–§22.7, including the frequency-limitation comparison table.
• All fees, allowed amounts, adjustments, denial rates, and staffing figures in Chapter 1 — constructed for teaching and labeled where they appear.
• All four arrangements in §19.1's 🔢 Code It.
• All RVU, GPCI, and conversion factor values in this chapter, and every figure derived from them. Constructed teaching figures — verify current values.
• All scenarios in this chapter: the four drug-table scenarios in §12.6, all exercise vignettes, and the decision trees in §12.3 and §12.10. Conventions and statutory framework are real; clinical situations are constructed.
• All scenarios in §15.5–§15.9, including the four data scenarios and the time examples.
• All scenarios in §18.1–§18.7, including the Account 22-9107 endoscopy report excerpt in §18.2.
• All units arithmetic in §20.3 and §20.4, including the methylprednisolone table and the 100 mg / 75 mg / "per 25 mg" exercise.
• All worked examples in this chapter: the drill-downs for M25.561, J44.1, E11.22, J96.01, and N18.31; the placeholder walkthroughs for W19.XXXA and T39.1X1A; and the seventh-character arc for S52.501A / D / S. The codes are real; the clinical scenarios attached to them are constructed.
• All worked scenarios in this chapter: the "probable pneumonia" two-setting contrast (§9.5), the integral and non-integral symptom examples (§9.6), the acute-on-chronic example (§9.8), and the exercises' clinical vignettes.
• Case Study 1, "A Year of Unwinnable Appeals" — the denials team, the MAI-2 category, the eleven-page appeal, and the new analyst's question. Constructed; the failure is ordinary.
• Case Study 1, "Four Nights, No Coverage" — the patient, the four observation nights, the notice delivered on day two. Mechanism and notice requirement real; patient and figures constructed.
• Case Study 1, "Items and Segments" — the practice, the vendor, the four months, and the biller who spoke both vocabularies. Constructed; the translation failure is ordinary.
• Case Study 1, "Modifier 25 Under Review" — constructed around the documented OIG interest and payer policy activity.
• Case Study 1, "The Address" — the move, three returned statements, a disconnected landline, and a collection placement. Constructed; the mechanism generates no signal inside the billing system.
• Case Study 1, "The Authorization That Didn't Match" — the practice, the two reschedules, the four drifts, and the months to resolve. Constructed; the mechanism is ordinary.
• Case Study 1, "The Category That Was Not There" — the eleven-provider group, the eight-row list, the payer's enrollment file lag, the two retrainings, the forty claims the front desk manager pulled. Constructed.
• Case Study 1, "The Folder Nobody Owned" — the practice, the departed supervisor, fourteen months, the improving denial rate. Constructed; the pattern is ordinary.
• Case Study 1, "The Package That Outlived the Coverage" — the obstetric practice, the job change at six months, the thirteen antepartum visits, and the split filing. Constructed; the mechanism is ordinary.
• Case Study 1, "The Practice That Never Changed Its Templates" — the twelve-physician group, the 1997-era templates, and the two-year interval. Pattern ordinary; organization and figures constructed.
• Case Study 1, "The Rest of the Vial" — the specialty practice, the written waste policy, the three years, and the purchasing-record reconciliation. Constructed; the detection method is real.
• Case Study 1, "The Rule That Stopped Being Right" — the fourteen-provider group, the CO rule, the payer's edit change, the physician's question. Constructed.
• Case Study 1, "The Standing Order" — the internal medicine practice, the patient, the four years of monthly panels, and the payer's utilization inquiry. Constructed; the pattern is a documented enforcement priority.
• Case Study 1, "Two Digits After the Acquisition" — the acquisition, the unchanged place of service default, and the payer's discovery. Constructed; the mechanism is ordinary.
• Case Study 1, "Where the Patient Went" — the hospital, the clerk, the eleven years, the extrapolated repayment. Constructed; the pattern is documented.
• Case Study 2 in its entirety — the four-physician practice, the twenty-claim review, the nineteen denials for unsigned orders, and the two-year exposure. A composite built from documented Medicare medical review findings and published contractor guidance; the requirements described are real, the practice is not.
• Case Study 2 in its entirety — the fourteen-physician cardiology practice, its unspecified heart failure rate, and the three causes with their proportions. Constructed; the pattern and mechanism are documented.
• Case Study 2 in its entirety — the nine-surgeon orthopedic practice, the 94% initial-encounter rate, and the pre-populated default. Constructed; the error is among the most common in injury coding.
• Case Study 2 in its entirety — the nine-year coder, the category expansion, the added instructional note, and the fourteen-month silent underreporting. Constructed; the mechanism is ordinary.
• Case Study 2 in its entirety — the primary care group, its recapture process, and the breast carcinoma coded as active for five consecutive years. Constructed; the failure mode is documented in risk-adjustment audit practice.
• Case Study 2 in its entirety — the regional hospital, the ED queue staffed by availability, and the pulmonary embolism example. Constructed; the rule is real and the failure mode is documented in audit practice.
• Case Study 2 in its entirety — the specialty practice, the revised descriptor, the fourteen months, and the payer review that found it. Constructed; the mechanism is ordinary and is the most dangerous routine event in the CPT calendar.
• Case Study 2 in its entirety — the two practices, the distal radius fracture, the ninety days of denials, and the patient's six hours on the telephone. Constructed; the collision is ordinary.
• Case Study 2 — the nine-provider practice, its seven scrubber rules, the eleven-year-old rule, and the \$61,400 self-reported overpayment. Constructed. The mechanism and the three questions in §6.5 are entirely ordinary.
• Case Study 2 — the twelve-physician group, 610 claims, \$74.20 average overpayment, \$45,262.00 repaid, \$82,662 total cost. A composite built from documented compliance guidance and the overpayment rule.
• Case Study 2's hospital system — a clearly labeled composite assembled from documented patterns; the professional-guidance history around it is real, the organization is not.
• Case Study 2, "Everybody Signs One" — the practice, the six years, the pre-printed form with a pre-checked option, and the family member's letter. Constructed; the routine-ABN problem is addressed explicitly in CMS's own ABN instructions.
• Case Study 2, "Four Lines of a Nursing Record" — the infusion center, the optional stop-time field, and the coder's aside in a meeting. Constructed; the mechanism is ordinary.
• Case Study 2, "Line One" — the surgical group, the charge-capture ordering, and the supervisor's contract-negotiation report. Constructed; the mechanism is arithmetic and the fix is a configuration setting.
• Case Study 2, "Ninety-Eight and a Half" — the practice, the six years at 98.5%, and the due diligence team's three findings. Constructed; all three findings are among the most-discussed topics in revenue cycle management.
• Case Study 2, "Page Twelve" — the fourteen months, the oral tradition that worked two-thirds of the time, and the requirement published three ways. Constructed.
• Case Study 2, "The Appeal the State Could Not Hear" — composite; the legal architecture (ERISA preemption, the four-month federal external review window) is Tier 1, the practice and timeline constructed.
• Case Study 2, "The Bilateral Convention Nobody Checked" — the ophthalmology practice, the three conventions, the four years, and the timely-filing recovery limit. Mechanism real; organization and figures constructed.
• Case Study 2, "The Criteria Nobody Could Produce" — the hospital, the nine-year-old criteria document, the nine-year distribution table, and the audit letter. Constructed; the document request is a real audit technique.
• Case Study 2, "The Fix That Was Being Undone" — the eleven-year configuration, the clearinghouse's transformation library, the migration, the eleven days. Constructed.
• Case Study 2, "The Practice That Became a Supplier" — the orthopedic practice, the braces, the eighteen months, and the supplier audit. Constructed; the improper payment rates and the "orders present, records empty" finding are documented.
• Case Study 2, "The Report That Got Received Well" — the coder, the manager, and both versions of the first conversation. Constructed; both paths are ordinary.
• Case Study 2, "The Template That Answered" — the seven-provider practice, the auto-inserted modifier 25 attestation, two years, the payer review. Constructed.
• Case Study 2, "The Twenty-Six-Hour Day" — the specialty practice, the prefilled default, and the 958-minute Tuesday. Figures constructed; the detection method is real.
• Case Study 2, "The Two Positions" — the administrator, the eliminated positions, the six-week lag, and the contract negotiation that surfaced it. Constructed; the decision was defensible on the evidence available.
• Case Study 2, "The Wrong Year" — the nine-provider practice, the sixty combinations, the three findings, the bounded recovery. Constructed.
• Case Study 2, "Three Days and a Corporate Chart" — the health system, the acquisitions, the payer's analytics. Constructed.
• Every allowed amount, contract percentage, and benefit position in this chapter's worked examples.
• Every fee schedule amount in this chapter, including the \$200.00, \$260.00, \$300.00, \$320.00, \$400.00, \$420.00, and \$500.00 used in limiting-charge calculations.
• Every field value in §25.10's reconstruction of Account 10-4471's claim. Consistent with §6.1, frozen since Ch. 6.
• Every figure in §26.9's counterfactual: \$148.60 professional, \$212.40 facility, \$361.00 total, \$84.52 patient, \$276.48 plan. **Internally consistent and reconciled to the frozen \$216.28 / \$47.58 independent case. Northgate is independent; the right-hand column did not happen.**
• Every figure in §28.11's remittance. All reconcile to frozen canon: §6.1's charges (185.00 / 150.00 / 18.00 / 14.00), Ch. 23's allowed amounts (128.40 / 78.60 / 6.28 / 3.00), Ch. 2's patient/plan split (47.58 / 168.70), and §6.2's day-17 EFT of \$70.30** and day-66 payment of **\$98.40. ✓
• Figure 13.1 — the schematic CPT page showing the joint injection codes and their parentheticals. Descriptors paraphrased and abridged; the real entries are longer and carry additional parentheticals.
• Figure 2.1, the Northfield Mutual Health Plan eligibility response — constructed in full, including member identifier, group number, and every accumulator value.
• Figure 3.1 — the LCD and companion billing-and-coding-article structure, shown schematically; the contractor, document numbers, and content are constructed.
• Figure 33.3's counterfactual "version B" H&P sentence, and the Encounter's hip-fracture counterfactual admission for Account 10-4471's patient — constructed lenses; the canonical files are unchanged.
• Figure 34.1's status-indicator grid — modeled on the structure of the published Addendum D1, paraphrased and grouped for teaching, explicitly not this year's assignments.
• Figure 34.3's returned-to-provider notice, the constructed audit claim in exercise E.23, and the Encounter's provider-based counterfactual for Account 10-4471 (Chapter 26 §26.9's figures, used unchanged) — constructed lenses; the canonical files are not altered.
• Figure 38.1's leading and compliant query drafts; §38.2's concurrent/retrospective timeline; §38.4's two CDI dashboards (400 records each; every rate recomputed and every category summed); §38.5's CAC pipeline, register entry, and document-completeness callout; §38.6's four-qualifier table; §38.7's autonomy test; §38.9's engine evaluation (1,905 suggested / 1,840 supported / 1,712 both; 22 unsupported accepted; 96 recovered by the reviewer) — all constructed, all labeled in place, all arithmetically checked, and none asserting a product's performance or an industry benchmark.
• Figure 4.1 — the paired leading and compliant queries. Constructed; the post-operative hemoglobin scenario is realistic and the values are invented.
• Figure 4.2 — the March 14 progress note for Account 10-4471, constructed in full. The canonical note for this book; every code assigned in Parts II and III derives from it.
• Figure 5.1 and Account 31-2245 — the shoulder arthroscopy claim, the 42-claim review, the \$612.40 average overpayment, and the \$25,720.80 demand. Constructed. The underlying coding relationships (an add-on code, a bundled debridement, a distinct-procedural-service modifier applied by macro) are real and are worked in Chapter 21 §21.9.
• Northgate Family Medicine, Ridgeview Regional Medical Center, and Northfield Mutual Health Plan — constructed organizations.
• Northgate's constructed charge-setting history and the Q6 resolution.
• The "knee, four ways" table in §7.7 and its named wrong answers.
• The 31-minute breakdown of touch 2 (6 + 5 + 3 + 10 + 7 = 31 ✓) and the practice's 21-day status-check rule (day 45).
• The acknowledgment report in §27.6's 📋 — batch 4471-0316, 38 claims, 36 accepted, 2 rejected with A3:21 and A7:562. Reconciles to the frozen §6.2 calendar's day 2 and day 3.
• The annotated SV1*HC:99214:25*185.00*UN*1***1:2:3:4~ segment. Reconciles to §6.1's charge (\$185.00), Ch. 14's modifier 25, and Ch. 25 §25.10's pointers.
• The charge-to-Medicare ratios in §23.7 — 191.67%, 237.04%, 330.88%, 466.67%.
• The constructed base-rate decomposition (labor \$4,216.00 × wage index, non-labor \$1,984.00), the constructed GMLOS figures and transfer arithmetic of §33.8, the five-stay GMLOS/AMLOS demonstration, and the five-discharge CMI example — all teaching figures, labeled where they appear.
• The constructed OPPS inputs introduced in this chapter: conversion factor \$85.00, clinic-visit weight 1.4000 (payment \$119.00; wage-adjusted \$122.57 at index 1.0500 and a 60% labor share), level 4 GI endoscopy weight 12.0000, ASC conversion factor \$42.50 (payment \$510.00), and the discounting drill at \$1,020.00 / \$450.00. All labeled where they appear; all internally consistent; none is anyone's real rate.
• The critical care time arithmetic in §16.7.
• The day-in-a-queue sketches in §6.8.
• The defective claim in §25.9's 📋 Read the Chart — five errors, one of them a coding error.
• The defective remittance in §28.5's 📋 Read the Chart — five findings, including a \$418.20 offset and an OA-23 on a claim marked primary.
• The defective UB-04 in §26.10's 📋 Read the Chart — five errors, and the diagnosis codes are all valid.
• The ED chart excerpt in §16.6 and the discharge summary excerpt in §16.4.
• The edit row in §21.2's 🔢 Code It and the six-step lookup walkthrough.
• The eligibility response in §24.4's 📋 Read the Chart.
• The Encounter's Medicare counterfactual allowed amounts: 99214 \$96.52, 20610 \$63.28, J1030 \$5.44, 36415 \$3.00, total \$168.24. Constructed; \$96.52 is derived in Chapter 23 §23.6.
• The entire §16.10 counterfactual — all levels, charges, and allowed amounts. Account 10-4471 was an office encounter; none of this happened.
• The estimate arithmetic in §24.9, built from Account 10-4471's contracted allowed amounts.
• The five worked lookups in §8.10 and their named wrong turns.
• The five-item sorting exercise in §26.6's 🔍 Check Your Understanding.
• The five-provider practice running through §31.2–§31.11: aging report (buckets 198,400 / 94,850 / 48,200 / 31,150 / 39,700 = 412,300; over-90 70,850 = 17.2%); days-in-AR inputs (twelve-month charges 2,920,000 → 8,000/day; 90-day charges 766,500 → 8,516.67/day; credits 28,600; write-off 67,900) producing 51.5 / 48.0 / 48.4 / 43.1; over-90 decomposition (16,400 + 21,300 + 9,850 + 10,600 + 12,700 = 70,850); credit report (9,300 + 7,850 + 8,900 + 2,550 = 28,600; oldest federal credit 194 days); dashboard page. All arithmetic verified; all labeled constructed. ⚠️ Deliberately NOT identified as Northgate — see continuity note on practice-scale consistency.
• The four adjustments in §28.4's 🔢 Code It.
• The four modifier 25 scenarios in §14.4; the modifier selection exercises; the decision trees in §14.9 and §14.11.
• The four readings of the same note in §15.10.
• The four rejection messages in §27.4's 🔢 Code It and their fixes.
• The four-charge outpatient encounter in §26.5's 🔢 Code It.
• The four-number measurement scenario in §17.4.
• The illustrative Medicare allowed amount of \$96.50 used in the §2.6 contract comparison, and the \$29.50 per member per month capitation rate in §2.6 and Case Study 2.
• The index excerpts in §8.2, §8.3, and §8.10 — the Pain(s) entry with joint subterms, the Hypertension nonessential modifiers, and the specialty table excerpts. These reproduce the structure of real entries and are abridged for teaching; complete entries are longer, which is itself a reason to work from your own book.
• The line in §28.5's 🔍 — charge \$150.00, allowed \$78.60, and a contract that says \$85.00.
• The Medicare Secondary Payer scenario in §24.7's 🔍 Check Your Understanding.
• The Medicare Summary Notice line in §3.9 and the payer-mix arithmetic in Exercise 3.17.
• The medication administration record excerpt in §19.9 and the infusion arithmetic built on it.
• The minutes in §27.7's 🧮 — 2–3 minutes at day 1 against a materially larger figure at day 120. Deliberately expressed in MINUTES and never multiplied by a rate; see §8.
• The minutes table in §24.1 and the ninety-to-one comparison. Deliberately in minutes rather than dollars — the loaded rate is Ch. 31 §31.7's, and the conversion for Account 10-4471 belongs to Ch. 40.
• The MUE arithmetic in §21.4 and the three-MAI comparison.
• The Northfield Mutual fee schedule used throughout: 99214 at \$128.40, 20610 at \$78.60, J1030 at \$6.28, 36415 at \$3.00. Constructed.
• The Northfield-versus-Medicare comparison table in §23.6, including the 128.55% blended rate. The arithmetic is exact; the underlying allowed amounts are Account 10-4471's constructed figures.
• The operative note excerpt in §21.8's 📋 Read the Chart — the note that would have supported the override.
• The operative note excerpts in §17.3 and §17.10, and all four notes in exercise Section I.
• The peer-to-peer prep sheet and constructed dialogue in §30.8.
• The pointer exercise in §25.5's 🔍 Check Your Understanding — the COPD, hypertension, and diabetes scenario.
• The procedure note excerpt in §20.3's 📋 Read the Chart.
• The provider-based counterfactual figures (\$84.52, 1.78×) — frozen in Ch. 26 §26.9.
• The referral excerpt in §22.10's 📋 Read the Chart and the Account 10-5502 walkthrough in §22.11.
• The repair scenarios in §17.5, including the four-laceration 🔍 Check Your Understanding.
• The semicolon convention example in §13.10 — real codes, paraphrased descriptors, shown structurally.
• The six denials in §29.2's 🔢 Code It.
• The six-item sorting exercise in §29.6's 🔍.
• The Table of Neoplasms excerpt in §10.4 — a real row in the real column order, abridged from a table running many pages.
• The therapy examples in §19.11, including the 8-and-8-minute case.
• The thirteen-row routing table in the Encounter checkpoint. Constructed as a teaching device; the source assignments are real.
• The three-procedure sequencing arithmetic in §18.8 and the anesthesia computation in §18.11.
• The three-scenario 🔍 Check Your Understanding in §21.7.
• The twelve-month payment plan arithmetic on \$439.28.
• The twelve-physician primary care group in Case Study 2 — a composite assembled from documented industry failure patterns and labeled as constructed within the case study.
• The underpayment arithmetic in §28.8's 🧮 — \$6.40 × 40/month × 26 months = \$6,656.00. Illustrative.
• The work-queue export in §29.5's 📋 Read the Chart — 412 open, 287-day oldest item, 138 closed with 49 resolved and 0 "no action," 104 uncategorized, sorted descending by charge.
• The §18.12 both-knees counterfactual for Account 10-4471. Did not happen; the March 14 note documents a right knee injection and a normal left knee.
• The §5.10 counterfactual note — the stripped two-line assessment that would not support modifier 25. Constructed as a deliberate contrast with Figure 4.2.
• §31.7's small-balance figures: statement cycle 2.95 (1.75 + 2 min × 0.60); balances 4.15 / 14.85; variance 2.40 × 1,150 = 2,760.00.
• §31.9's worked recoupment sequence and Section G exercise demand (1,840.00 across six claims).
• ⚠️ Figure 40.2's distribution and the 41% — the sort of Northgate's 267 denied lines by allowed amount, constructed for this chapter. The method generalizes; the number does not.