R1 rules and experts uncovered coding guidance issue

Situation

In the course of our work with customers, R1 operators occasionally identify ambiguities and errors in guidance from regulatory agencies and industry associations that can potentially cause operational bottlenecks and revenue losses. In our inaugural Experts in Action story, we focused on a CMS error involving the Integrated Outpatient Code Editor our expert operators discovered, researched and resolved. This time we’re exploring a coding guidance error initially flagged by R1 coding rules.

The first quarter 2025 newsletter from the AHA Coding Clinic®, released in March 2025, included updated coding guidance for Neoatherosclerosis of Coronary Artery Stent. The R1 team, supported by the industry’s richest coding rules set, identified an issue with the new guidance that put it in conflict with existing guidance and the best practices we share with customers.

Opportunity

R1 submitted the issue to AHA Coding Clinic for clarification with examples and reasoning.

“Correction Notices are rare,” said Margaret Mariani, vice president of DRG Validation Intelligence at R1. “AHA Coding Clinic is the governing body that provides expert advice on complex coding scenarios. Based on our submission and examples, along with input from providers, they reversed the sequencing guidance from the prior issue. The clarification supported R1’s coding logic related to myocardial infarction and across our client base, preserved millions in annual provider revenue.”

 AHA Coding Clinic issued a rare Correction Notice in their Q2 issue published on June 13, 2025. The correction rescinded the first quarter guidance and confirmed historical code sequencing guidance.

Results

The correction preserves an estimated in annualized savings for R1 DRG Validation clients reporting these codes in the correct sequence per ICD10-CM Official Coding Guidelines.

“As we analyzed the potential provider impact, we found that among cases with this coding scenario, the new guidance would have impacted the DRG for 55% of them,” said Mariani. “A small subset would have seen a marginally positive impact, but the majority would have resulted in significant lost revenue due to a lower weighted DRG.”

This rare case of faulty guidance from a trusted, authoritative institution underscores the importance of proactive regulatory monitoring and expert interpretation in revenue cycle operations. For coding professionals and healthcare organizations, the takeaway is clear – staying current isn’t enough.  Challenging guidance when it conflicts with established best practices can protect revenue while ensuring compliance.

Our embedded subject matter experts serve as a frontline safeguard against potentially costly errors, offering not just technical accuracy but strategic foresight. This correction preserved millions in client revenue and reinforced the value of having a team that not only understands the rules but helps to revise and update them.

R1 operators and technologies constantly monitor for anomalies and variances indicating potential process or operational issues – whether directly for R1 or on clients’ internal teams.  Our technology, expertise and deep relationships with this and other industry bodies drive significant benefit for our clients by delivering best practices, professional development and continuing education, time savings and, ultimately, preventing lost revenue.