Navigating Healthcare Excellence with UASI

Acute Hospital Care at Home: CMS Signals a Shift in Risk Adjustment and Payment Models

Thu, 30 Apr 2026 20:00:54 GMT

Acute Hospital Care at Home: CMS Signals a Shift in Risk Adjustment and Payment Models

By Leah Jeffries, Director, Audits & Assessments, UASI

Hospital-at-Home, CMS Evidence, and a Quiet Signal on Risk Capture

In April 2026, CMS issued a Federal Register notice seeking public comment on the continued information collection requirements for the Acute Hospital Care at Home (AHCAH) program. While technical on its surface, the notice is strategically significant. It follows CMS’s completion of the first congressionally required national evaluation of hospital-at-home outcomes and signals a broader shift in how Medicare uses clinical and diagnostic data, not only to finance care through Medicare Advantage, but also to evaluate, compare, and ultimately design alternative payment models across fee-for-service programs.

Historically, Risk Adjustment Factor (RAF) scores and Hierarchical Condition Category (HCC) coding have been viewed primarily as a Medicare Advantage construct, used to prospectively translate population complexity into capitated payments for MA plans. Increasingly, however, CMS is leveraging those same risk adjustment mechanisms as analytic infrastructure to assess care delivery models, normalize patient complexity, and anchor episode-based and site-neutral payment strategies. Medicare is no longer using RAF data solely to pay plans. It is also using it to determine which care models demonstrate value, which scale, and which may ultimately become mandatory.

This shift is already visible in CMS’s broader policy direction, including the initiation of the TEAM, or Transforming Episode Accountability Model, an alternative payment model that explicitly relies on accurate documentation and diagnosis capture to align episode spending targets, benchmark provider performance, and assess financial risk. In this context, coding accuracy and documentation integrity are no longer secondary compliance functions. They are foundational inputs into how CMS evaluates value and structures payment across the healthcare system.

CMS Findings on Acute Hospital Care at Home Outcomes

In September 2024, CMS released its final evaluation of the AHCAH program, analyzing more than 13,000 hospital-at-home inpatient episodes compared with nearly 1 million traditional inpatient stays across 332 participating hospitals. For appropriately selected patients, CMS identified strong performance signals, including lower 30-day mortality across major diagnosis groups, meaningfully reduced post-discharge Medicare spending, lower utilization of intensive hospital services, positive patient, caregiver, and clinician experiences.

Patient Complexity and Risk Adjustment Factor Scores in Fee-for-Service Medicare

At the same time, CMS was explicit that AHCAH patients differed materially from the broader inpatient population. Patients treated at home were, on average, less clinically complex based on mean and median RAF scores, less likely to be dual eligible for Medicaid, and more likely to reside in stable urban environments. These differences were not treated as limitations of the study. They were central to how CMS interpreted the results.

How CMS Uses HCC Coding to Evaluate Care Delivery Models

Notably, CMS relied heavily on HCC-derived risk scores to compare populations, contextualize mortality and utilization differences, and interpret spending outcomes. This is significant because AHCAH operates under Medicare fee-for-service, not Medicare Advantage. In this evaluation, the HCC code captured functioned not merely as a payment mechanism but as a core policy, statistical criteria, and analytic tool.

What This Means for Medicare Fee-for-Service Payment Models

From an industry perspective, AHCAH represents more than an alternative site of care. It is an early and visible example of how CMS is integrating risk adjustment into fee-for-service evaluation and alternative payment model design. Coding and documentation practices that were once viewed primarily through a Medicare Advantage lens are increasingly central to how CMS assesses quality, safety, equity, and cost across new care models.

The Expanding Role of Risk Adjustment Across Medicare Programs

This marks a meaningful shift. Diagnosis accuracy is no longer confined to MA revenue optimization. It is becoming a prerequisite for participation in episode-based models, mandatory payment programs, and capacity relief strategies. Hospital-at-home may serve as a compelling case study today, but its implications extend broadly across the Medicare landscape.

From our perspective, this evolution highlights a critical reality. As CMS continues to test and scale alternative payment models, the integrity of clinical documentation and code capture will directly influence not only reimbursement but also the evaluation, sustainability, and regulation of alternative care models. AHCAH may represent the beginning of this shift, but it is unlikely to be the end.

Leah Jeffries, RHIT, CDIP, CCS, CCS-P

Director, Audits and Assessments

Additional Resources

MedPAC (Medicare Payment Advisory Commission). (2023). Report to the Congress: Medicare Payment Policy (risk adjustment and Medicare payment systems). Available at: medpac.gov/document/march-2023-report-to-the-congress-medicare-payment-policy

Office of the Federal Register. (2023). Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence. Available at: federalregister.gov/documents/2023/11/01/2023-24283/safe-secure-and-trustworthy-development-and-use-of-artificial-intelligence

Pregnancy ICD-10 Coding Refresher: Chapter 15 Guidelines and Trimester Selection

Thu, 30 Apr 2026 18:46:25 GMT

Pregnancy ICD-10 Coding Refresher: Chapter 15 Guidelines and Trimester Selection

Understanding Chapter 15: Pregnancy, Childbirth, and the Puerperium

Chapter 15 in ICD-10-CM covers the Pregnancy, Childbirth, and the Puerperium (O00-O9A) codes. It is important to code according to the guidelines to avoid denials.

All pregnancy cases should have a secondary code assigned to represent the weeks of gestation (Z3A.00-Z3A.49). Chapter 15 codes and weeks of gestation codes are only to be assigned on the maternal record.

Using the ICD-10-CM Tabular for Pregnancy Code Selection

Use the coding tabular to help determine what Chapter 15 code should go before the diagnosis. It lists what codes fall under each category. See example below:

Determining Trimester Based on Weeks of Gestation

Once you determine what category your diagnosis falls under, the last character in that code will be what trimester the patient is in during her pregnancy at the time of the visit. Trimesters can be figured out by the week of gestation. If the patient is 11 weeks and 2 days pregnant, code to the week of last completion, which would be 11 weeks in this case.

1st trimester: week 1-13
2nd trimester: week 14-27
3rd trimester: week 28-birth

Pregnancy Coding Example: Epilepsy in the Second Trimester

Example: A pregnant mom has epilepsy, and she is at 15 weeks of gestation.

The codes would be: O99.352, G40.909 and Z3A.15.

Explanation: O99.352 is used because the patient has a neurological disorder and is in the 2nd trimester. G40.909 is used to further describe the disorder – epilepsy. Z3A.15 describes the patient being 15 weeks pregnant. Most diagnoses will be coded as a pair for a pregnant patient – one code from Chapter 15 and one from another chapter to further describe the condition. Lastly, you will have the Z code for weeks of gestation.

Katie Brown, CCS

Senior Consultant, Audit at UASI

Katie Brown, CCS, is an AHIMA-certified Senior Coding Consultant specializing in CPT/ICD-10 coding, compliance audits, and revenue cycle support. She’s worked across diverse outpatient and inpatient settings, including ER, surgery, observation, and specialty clinics, and enjoys training coders with practical, CDI-friendly tips.

Works Cited

Centers for Medicare & Medicaid Services . (2025). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026.

Healthy Blue Kansas. (2024). Pregnancy coding and billing guidance. Available at: https://www.healthybluekansas.com

Welcome Cindy Smith

Mon, 27 Apr 2026 17:03:10 GMT

UASI Names Cindy Smith as Managing Consultant, Managed Services & Strategy

UASI is pleased to announce the appointment of Cindy Smith as Managing Consultant of Managed Services & Strategy. Cindy brings more than 35 years of Revenue Cycle Management experience, with expertise in inpatient and outpatient coding, auditing, and Health Information Management (HIM) consulting.

Cindy returns to UASI after 24 years, where she previously led coding and review services, overseeing nationwide consulting teams and ensuring compliance and quality standards. Her return highlights both her longstanding connection to the organization and UASI’s commitment to experienced, client-focused leadership.

Throughout her career, Cindy has partnered with a wide range of healthcare facilities and provider groups, providing strategic guidance, coding education, and audit services. She is known for her strong communication skills and her ability to listen closely to client needs, building lasting relationships and delivering tailored solutions.

Prior to rejoining UASI, Cindy served as Senior Client Development Manager at AQuity Solutions (now IKS Health), where she collaborated with client leaders and operational teams to support coding services and strengthen client partnerships while contributing to client growth.

“Cindy’s return to UASI is incredibly meaningful for our organization,” said Nancy Koors, CEO of UASI. “Her experience, leadership, and ability to build strong client partnerships make her an outstanding addition to our team.”

In her role as Managing Consultant of Managed Services & Strategy, Cindy will play a key role in advancing UASI’s strategic initiatives by strengthening client partnerships, supporting the development of high-performing teams, and delivering consultative solutions that drive operational and financial performance. Her extensive background in coding education, auditing, and HIM consulting will further enhance UASI’s ability to provide impactful, client-centered services.

How to Code Thyroid Eye Disease (TED) with New ICD-10-CM Codes

Wed, 22 Apr 2026 15:50:01 GMT

How to Code Thyroid Eye Disease (TED) with New ICD-10-CM Codes

New ICD-10-CM diagnosis codes are now available to capture thyroid eye disease (TED) with greater specificity. These codes improve the ability to identify affected patients, support clinical tracking, and strengthen documentation for research, quality reporting, and patient outcomes.

What Is Thyroid Eye Disease (TED)?

Thyroid eye disease is an autoimmune inflammatory condition affecting the tissues around the eyes. Common features include:

Bulging eyes (proptosis)
Pain or pressure
Dryness or irritation
Swelling of the eyelids
Possible vision changes

TED is most commonly associated with Graves’ disease (hyperthyroidism) but may also occur with:

Hashimoto’s thyroiditis
Hypothyroidism
Euthyroid states

New ICD-10-CM Codes for Thyroid Eye Disease

These codes allow documentation of laterality, improving accuracy and supporting medical necessity for treatment:

Treatment Considerations for Thyroid Eye Disease

These codes may be used to support medical necessity for treatments such as:

Teprotumumab (Tepezza) – the first FDA-approved therapy specifically for TED
Corticosteroids for inflammation control
Radiation therapy in more severe or refractory cases

Coding Example & Reminder for Thyroid Eye Disease

*** Reminder: Don’t Forget Associated Thyroid Diagnoses. Always code the underlying thyroid condition to provide a complete clinical picture and support medical necessity.

Coding Example

Final diagnosis: Graves’ disease with thyroid eye disease affecting both eyes.

Codes:

H05.833 – Thyroid orbitopathy, bilateral
E05.00 – Hyperthyroidism with goiter

Melanie Perrault, RHIA, CDIP, CCS

Senior Consultant, Audit at UASI

Melanie Perrault is a Senior Consultant in Quality at UASI, with extensive expertise in inpatient coding, CDI, and documentation integrity. She brings a strong educator’s mindset to her coding tips, helping coders and CDI teams strengthen clinical clarity, accuracy, and audit-ready compliance.

Works Cited:

American Hospital Association. (2025). Thyroid eye disease coding guidance. AHA Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2025, p. 17.

Centers for Medicare & Medicaid Services. (2026). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026.

Hypercholesterolemia: When to Assign E78.0 vs Other Lipid Disorder Codes

Thu, 16 Apr 2026 18:48:43 GMT

Hypercholesterolemia ICD-10 Coding: When to Assign E78.0 vs Other Lipid Disorder Codes

Understanding Hypercholesterolemia in ICD-10-CM Coding

Hypercholesterolemia refers specifically to elevated cholesterol levels , most commonly elevated LDL cholesterol. In ICD-10-CM, it falls under category E78.- Disorders of lipoprotein metabolism and other lipidemias .

It is important for coders to distinguish hypercholesterolemia from broader lipid disorders, as code selection depends on the type of lipid abnormality documented .

ICD-10-CM Code Assignment for Hypercholesterolemia

When documented, hypercholesterolemia is reported with:

E78.0 – Pure hypercholesterolemia

Subclassification includes:

E78.00 – Pure hypercholesterolemia, unspecified
E78.01 – Familial hypercholesterolemia

Use subcategory E78.01- when documentation clearly identifies a genetic or familial condition. Otherwise, assign E78.00 when no further specificity is provided.

Differentiating Hypercholesterolemia from Other Lipid Disorders

Accurate code selection requires understanding how hypercholesterolemia differs from other lipid conditions:

E78.0- → Cholesterol only (pure hypercholesterolemia)
E78.1 → Elevated triglycerides (hyperglyceridemia)
E78.2 → Mixed hyperlipidemia (cholesterol + triglycerides)
E78.5 → Hyperlipidemia, unspecified

Do not assign E78.0- if documentation supports mixed or combined lipid abnormalities .

Coding Tips for Accurate Assignment

Code the condition as documented by the provider , not based on lab values alone.
Do not assume hypercholesterolemia from elevated LDL unless explicitly documented.
Avoid defaulting to E78.5 (unspecified hyperlipidemia) when documentation supports a more specific diagnosis.

Review the record for:

Problem list documentation
Assessment/plan statements
History of familial lipid disorders

Common Coding Pitfalls

Assigning E78.00 when documentation only states “hyperlipidemia”.
Using unspecified codes when the provider has documented a specific lipid abnormality elsewhere in the record.
Coding based solely on lab findings without provider confirmation.
Failing to identify familial hypercholesterolemia (E78.01-) when documented.

FY 2026 Coding Considerations

Code E78.01, Familial hypercholesterolemia was expanded:

E78.01 0 - Homozygous familial hypercholesterolemia (HoFH)
E78.011 -Heterozygous familial hypercholesterolemia (HeFH)
E78.019 - Familial hypercholesterolemia, unspecified

Heterozygous familial hypercholesterolemia (HeFH) occurs when an individual inherits the variant (mutated) gene from one parent. HeFH is the most common type and can be defined as LDL-C levels above 190 mg/dL. Homozygous familial hypercholesterolemia (HoFH) occurs when an individual inherits the variant gene from both parents. HoFH is the most severe type, and if untreated, could result in LDL-C levels above 400 Mg/dL.

Coding expectations remain consistent:

Assign the most specific code available
Follow provider documentation
Ensure correct differentiation between lipid disorder types

Lori Amende, RHIA, CCS

Education and Quality Manager at UASI

Works Cited

Centers for Medicare & Medicaid Services. (2025). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026.

National Heart, Lung, and Blood Institute. (2023). High blood cholesterol. Available at: https://www.nhlbi.nih.gov

National Library of Medicine. (2024). High blood cholesterol (hypercholesterolemia). MedlinePlus Medical Encyclopedia. Available at: https://medlineplus.gov/ency/article/000403.htm

Encephalopathy Coding: Types, Guidelines, and Documentation Tips

Thu, 16 Apr 2026 18:28:12 GMT

Encephalopathy ICD-10-CM Coding: Types, Guidelines, and Documentation Tips

Overview of Encephalopathy

Encephalopathy refers to a broad category of brain dysfunction that can result from a variety of underlying conditions, including metabolic disturbances, infections, toxins, hypoxia, or organ failure.

It is commonly seen in inpatient settings and often represents a clinically significant condition that impacts severity of illness, resource utilization, and patient outcomes.

Types of Encephalopathy and ICD-10-CM Codes

Accurate coding depends on identifying the underlying cause and type of encephalopathy documented.

Common ICD-10-CM codes include:

G93.40 – Encephalopathy, unspecified
G93.41 – Metabolic encephalopathy
G93.49 – Other encephalopathy

Additional related codes based on etiology:

K76.82 – Hepatic encephalopathy
F05 – Delirium due to known physiological condition
Toxic encephalopathy → code from T36–T65 with 5th/6th character for intent

Code assignment should reflect the most specific type of encephalopathy documented .

Documentation Requirements for Accurate Coding

Provider documentation should clearly identify:

The type of encephalopathy (metabolic, toxic, hepatic, anoxic, etc.)
The underlying cause or condition
Clinical indicators supporting the diagnosis

Avoid use of unspecified encephalopathy (G93.40) when further clarification is supported by the clinical picture.

Coding and CDI Tips for Encephalopathy

Differentiate encephalopathy from delirium or altered mental status when possible

Query when documentation uses nonspecific terms such as:

“AMS”
“confusion”
“encephalopathic changes”

Link encephalopathy to underlying causes (e.g., sepsis, renal failure, liver disease, medications)

Recognize that metabolic encephalopathy (G93.41) is a MCC and impacts severity capture

Review labs and clinical indicators such as:

Elevated ammonia
Electrolyte imbalance
Hypoxia
Infection markers

Clinical Indicators Supporting Encephalopathy

Common clinical indicators may include:

Altered level of consciousness
Confusion or disorientation
Lethargy or agitation
Abnormal EEG findings
Metabolic abnormalities (e.g., sodium imbalance, uremia, hyperammonemia)

Treatment may include:

Correction of underlying cause
IV fluids
Electrolyte replacement
Lactulose (for hepatic causes)
Antibiotics (if infectious etiology is present)

Query Opportunities for Encephalopathy

A query may be appropriate when:

Documentation reflects altered mental status without a defined diagnosis
Clinical indicators support a metabolic or toxic etiology
There is a known underlying condition (e.g., sepsis, renal failure) with neurologic changes

FY 2026 Coding Considerations

ICD-10-CM classification for encephalopathy remains stable in FY 2026, with continued emphasis on:

Coding the specific type and underlying cause
Avoiding unspecified diagnoses when documentation supports specificity
Capturing conditions that impact CC/MCC status and SOI/ROM

Lori Amende, RHIA, CCS

Education and Quality Manager at UASI

Works Cited

Centers for Medicare & Medicaid Services. (2025). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026.

American Hospital Association. (2024). Encephalopathy coding guidance. AHA Coding Clinic for ICD-10-CM/PCS.

National Library of Medicine. (2024). Encephalopathy. MedlinePlus Medical Encyclopedia. Available at: https://medlineplus.gov/ency/article/001415.htm

Non-Infectious SIRS: Documentation and Coding Considerations

Thu, 16 Apr 2026 13:28:49 GMT

Non-Infectious SIRS: Documentation and Coding Considerations

Non-infectious SIRS (systemic inflammatory response syndrome) with or without organ dysfunction is an inflammatory response not due to infection.

Clinical Indicators of Non-Infectious SIRS

Two or more of the following:

Temp >38°C (100.4°F) or <36°C (96.8°F)
WBC >12,000/microL or <4,000/microL or Bands >10%
Heart Rate >90 beats/min
Respiratory rate >20 breaths/min

Common Conditions Associated With Non-Infectious SIRS

Non-infectious SIRS seen in patients with pancreatitis, acute mesenteric ischemia, burns, major surgical procedures, advanced malignancies, major traumas, tumor lysis syndrome, myocardial infarction and transfusion reactions.

ICD-10-CM Coding for Non-Infectious SIRS

Codes are given based on whether acute organ dysfunction is present:

R65.10, SIRS of noninfectious origin without acute organ dysfunction (CC)
R65.11, SIRS of noninfectious origin with acute organ dysfunction (MCC)
Per the Excludes 1 note, SIRS is not reported if sepsis is present
If documentation is not clear concerning whether SIRS is related to acute organ dysfunction, the provider should be queried

Acute Organ Dysfunction Considerations

Possible acute organ dysfunction includes but is not limited to: acute respiratory failure, AKI, acute metabolic encephalopathy, critical illness myopathy, and disseminated intravascular coagulation (DIC).

CDI Query Prompt for SIRS Clarification

Can you please specify if you are treating and/or monitoring any of the following conditions?

Noninfectious SIRS with acute organ dysfunction
Noninfectious SIRS without acute organ dysfunction
Other, please specify

Clinical Indicators:

Admitted for acute pancreatitis

VS: HR 100–122, RR 22–30, WBCs on admit 18K, Temp 101.2

Blood/Urine cultures negative

Treatments include pain medication and IV fluids

Alyce Reavis, RN,MSN,CCDS,CCS

Senior CDI Educator, Consulting Services at UASI

Drawing on clinical experience in adult, pediatric, and neonatal acute care, Alyce brings valuable insight to CDI education and documentation improvement. She holds an MSN in Leadership/Education along with CCDS, CCS, and AHIMA’s outpatient CDI micro credential, supporting health systems in strengthening documentation accuracy, quality reporting, and reimbursement integrity. Passionate about truthful, clinically aligned health records, she helps organizations ensure documentation reflects true patient acuity. She is a past presenter

Works Cited

Centers for Medicare & Medicaid Services. (2025). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026.
Available at https://www.cms.gov/files/document/fy-2026-icd-10-cm-coding-guidelines.pdf

American Hospital Association. (n.d.). Systemic inflammatory response syndrome (SIRS) and organ dysfunction. Coding Clinic for ICD-10-CM/PCS. Available at https://www.ahacentraloffice.org/aha-coding-clinic

When to Query for Acute Respiratory Failure with Hypoxia (J96.01)

Wed, 15 Apr 2026 20:16:47 GMT

When to Query for Acute Respiratory Failure with Hypoxia (J96.01)

Acute Respiratory Failure with Hypoxia: What Coders Need to Look For

Acute respiratory failure with hypoxia is frequently encountered in the inpatient setting, but it is also one of the most commonly missed or under-documented conditions from a coding and CDI perspective.

Patients may present with low oxygen saturation, increased work of breathing, or require escalating oxygen support—but those findings alone are not enough for code assignment. Clear provider documentation is required to report respiratory failure.

Understanding J96.01 and Related ICD-10-CM Codes

When documented, acute respiratory failure with hypoxia is reported with:

J96.01 – Acute respiratory failure with hypoxia

Other ICD-10-CM codes associated with acute respiratory failure

J96.02 – Acute respiratory failure with hypercapnia (acute respiratory acidosis yields the same code)
J96.21 – Acute and chronic respiratory failure with hypoxia
J96.22- Acute and chronic respiratory failure with hypercapnia

The key distinction is whether the provider identifies hypoxia, hypercapnia, or both , as well as whether the condition is acute alone or an acute process on top of a chronic failure.

Clinical Picture: When Hypoxia Becomes Respiratory Failure

Hypoxia alone may not meet criteria for respiratory failure. However, the following patterns often support the diagnosis when documented:

Oxygen saturation below 90% on room air
PaO2 less than 60 mmHg
Escalation to high-flow oxygen, BiPAP, or mechanical ventilation, nasal cannula with O2 flow at FiO2 >/= 40% for a prolonged period.
Increased respiratory effort (tachypnea, accessory muscle use)
Changes in mental status related to oxygenation

These indicators should always be interpreted in context and supported by provider documentation.

Documentation Gaps That Create Missed Coding Opportunities

One of the most common issues is documentation of respiratory symptoms rather than a diagnosis. Examples include:

“Hypoxia”
“Shortness of breath”
“Respiratory distress”

These terms do not translate to respiratory failure for coding purposes .

If the clinical picture supports it, a query may be appropriate to clarify whether acute respiratory failure is present and to specify the type.

CDI Tip: Watch for Escalation in Respiratory Support

A key signal for potential query opportunity is treatment escalation .

If a patient progresses from:

Room air → nasal cannula → high-flow oxygen
Or requires BiPAP or intubation

This often indicates a level of severity consistent with respiratory failure—especially when paired with abnormal labs or vital signs.

Why This Diagnosis Matters

Acute respiratory failure can provide an MCC to a case and plays an important role in:

Severity of illness (SOI/ROM)
DRG assignment
Accurate representation of clinical complexity

Failure to query when clinically supported can understate the patient’s condition and impact reporting accuracy.

FY 2026 Coding Considerations

There are no structural changes to respiratory failure codes in FY 2026 , but expectations remain clear:

Report the most specific code that reflects the provider’s documentation and the supporting clinical indicators
Review for specificity of respiratory failure and query where appropriate
Ensure linkage to the etiology of respiratory failure is noted with phrases such as, “due to”, “caused by”, and “associated with” for example/

As always, specificity and clarity in documentation drive accurate coding.

Query Opportunity: Clarifying Acute Respiratory Failure with Hypoxia

A query may be appropriate when clinical indicators suggest respiratory failure, but the provider's documentation does not clearly establish the diagnosis.

Example Scenario:
The patient presents with oxygen saturation of 86% on room air, requires escalation to high-flow oxygen, and demonstrates increased work of breathing. Documentation reflects “hypoxia” and “respiratory distress,” but does not specify respiratory failure.

Example Query:

Dr. _________

Please review the below clinical indicators and clarify the respiratory status of the patient for this encounter. For example:

Acute respiratory failure with hypoxia
Acute on chronic respiratory failure with hypoxia
Other explanation of clinical findings

Clinical Indicators:

H&P: “Patient reports to the ER with complaints of shortness of breath. On my exam, it is noted that there is increased work of breathing and accessory muscle use. Patient will be admitted to the medical floor for pneumonia seen on chest XRAY and hypoxia.”
ABG on admit: PaO2 55 mmHg
VS: respiratory rate 28-32 breaths per minute; SpO2 is 86% RA in the ER.

Risk Factors:

Pneumonia
CHF exacerbation
COPD exacerbation

Treatment:

6L O2 via nasal cannula with titration as tolerated to maintain SpO2 >/= 92%

Thank you,

CDI Specialist

Alyce Reavis, RN,MSN,CCDS,CCS

Senior CDI Educator, Consulting Services at UASI

Works Cited

Centers for Medicare & Medicaid Services. (2025). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026.

American Hospital Association. (2024). Respiratory failure coding guidance. AHA Coding Clinic for ICD-10-CM/PCS.

National Library of Medicine. (2024). Respiratory failure. MedlinePlus Medical Encyclopedia. Available at: https://medlineplus.gov/ency/article/000127.htm

How MASLD and MASH Translate to ICD-10-CM Coding

Tue, 07 Apr 2026 15:21:49 GMT

MASLD and MASH vs NAFLD and NASH: ICD-10-CM Coding Guidance

Overview of Evolving Liver Disease Terminology

ICD-10-CM Coding Quality Education Tip

Clinical terminology has evolved; ICD-10-CM coding has not yet fully aligned.

MASLD vs NAFLD: Coding Considerations

MASLD – Metabolic dysfunction–Associated Steatotic Liver Disease
A clinical term describing fatty liver disease associated with metabolic dysfunction (e.g., obesity, diabetes, dyslipidemia).
NAFLD – Nonalcoholic Fatty Liver Disease
The current ICD-10-CM terminology used to classify fatty liver disease not due to alcohol.
ICD-10-CM Status: ICD-10-CM does not yet recognize MASLD as a distinct diagnosis.
Coding Guidance:
Assign the most accurate NAFLD-related ICD-10-CM code based on documentation.
K76.0 – Fatty (change of) liver, not elsewhere classified
Query if alcohol use, metabolic risk factors, or disease etiology are unclear.

MASH vs NASH: Coding Considerations

MASH – Metabolic dysfunction–Associated Steatohepatitis
A clinical term describing steatohepatitis associated with metabolic dysfunction.
NASH – Nonalcoholic Steatohepatitis
The current ICD-10-CM terminology for nonalcoholic steatohepatitis.
ICD-10-CM Status: There is no distinct ICD-10-CM code for MASH at this time.
Coding Guidance:
When documentation states metabolic dysfunction–associated steatohepatitis, report:
K75.81 – Nonalcoholic steatohepatitis
Confirm documentation supports steatohepatitis and excludes alcohol-related liver disease.

Key ICD-10-CM Coding Takeaways

Code to the ICD-10-CM classification, not evolving clinical terminology.
Metabolic dysfunction–Associated Steatotic Liver Disease → Nonalcoholic Fatty Liver Disease ICD-10-CM codes.
Metabolic dysfunction–Associated Steatohepatitis → Nonalcoholic Steatohepatitis (K75.81).
Query when documentation lacks specificity or conflicting terminology is used.

Works Cited

American Association for the Study of Liver Diseases (AASLD) . (2023). New nomenclature for NAFLD and NASH. Available at: https://www.aasld.org/practice-guidelines/new-nomenclature-nafld-and-nash

Journal of Hepatology . (2023). A new definition for metabolic dysfunction–associated fatty liver disease. Available at: https://www.journal-of-hepatology.eu/article/S0168-8278(23)00093-0/fulltext

Centers for Disease Control and Prevention . (2024). ICD-10-CM. Available at: https://www.cdc.gov/nchs/icd/icd-10-cm.htm

Centers for Medicare & Medicaid Services . (2024). ICD-10 coding resources. Available at: https://www.cms.gov/medicare/coding/icd10

AAOLCA Transconal Unroofing

Mon, 06 Apr 2026 19:44:37 GMT

ICD-10-PCS Coding for AAOLCA Transconal Unroofing Procedure

Overview of AAOLCA and Transseptal Coronary Anatomy

Anomalous Aortic Origin of the Left Coronary Artery (AAOLCA) – Transseptal/Intraseptal Course

Diagnosis: Q24.5 – Malformation of coronary vessels

What is AAOLCA?

Anomalous Aortic Origin of the Left Coronary Artery (AAOLCA) is a congenital anomaly in which the left coronary artery arises from the right aortic sinus instead of the left sinus. In the transseptal/intraseptal variant, the artery takes an abnormal course behind or within the right ventricular outflow tract (RVOT) wall, often with an intramural segment. This can cause compression between the great vessels during exercise.

Clinical Risks Associated with AAOLCA

Myocardial ischemia
Sudden cardiac arrest or sudden cardiac death (especially in young athletes during exertion) AAOLCA is considered higher risk than the right-sided variant and is a leading cause of sudden cardiac death in young athletes.

Procedure Overview: Najm Transconal Unroofing Technique

Developed by Hani K. Najm, MD (Cleveland Clinic), the transconal unroofing procedure repairs AAOLCA with transseptal course. It includes right ventriculotomy, complete unroofing/exteriorization of the left coronary segment from its muscular bed (releasing compression), creation of a widened neo-ostium, separation from the compressive RVOT, and posterior elongation of the RVOT with an autologous pericardial patch. The coronary artery remains in situ.

Anatomic corrective repair — Do not use bypass codes (section 021).

ICD-10-PCS Coding Principles for Transconal Unroofing

Coronary Arteries: Code by number of sites treated (usually “One Artery”). Do not name branches (B4.4).
Approach: Always Open (0).
Unroofing of anomalous coronary artery (intramural/transseptal segment) to remove constriction and improve the ostium → Root operation Release.
RVOT patch: Supplement
Device: Z (No Device) for coronary unroofing; tissue substitute for RVOT patch.

Procedure Components and ICD-10-PCS Code Assignment

Coding Decision Guide for AAOLCA Repair

Transseptal coronary segment unroofed to release constriction? → Release Coronary Artery (02N0xZZ).
Right ventriculotomy + RVOT patch elongation? → Add Supplement Right Ventricle (02UK0xZ).
Patch material:
Autologous pericardium → Autologous Tissue Substitute (7)
Bovine pericardium → Nonautologous Tissue Substitute (K)
Multiple coronary sites? Code to highest number treated.

Additional Coding and Documentation Tips

Cardiopulmonary bypass and sternotomy are integral (do not code separately).
Query surgeon for: number of coronary sites, exact patch material, and confirmation of “in situ” unroofing.
Differs from standard intramural unroofing due to transconal exposure and RVOT reconstruction.
AHA Coding Clinic (2nd Quarter 2019, pp. 13-14) explicitly assigns Release for unroofing of anomalous coronary artery to remove constriction and improve the ostium.

Tracy Blevins is a Senior Consultant in Quality Auditing at UASI, with 14+ years of inpatient medical coding and health information management experience. As a Registered Health Information Administrator that also holds AHIMA’s Auditing Inpatient Coding Microcredential, she shares practical, detail-driven coding tips to help clinicians and coders strengthen documentation, accuracy, and compliance.

Works Cited

Najm, H. K., & Ahmad, M. (2019). Transconal unroofing of anomalous left main coronary artery from right sinus with transseptal course. Annals of Thoracic Surgery. Available at: https://www.annalsthoracicsurgery.org/article/S0003-4975(19)30694-0/fulltext

Najm, H. K., et al. (2021). Early outcomes of transconal repair of transseptal anomalous aortic origin of left coronary artery. Annals of Thoracic Surgery. Available at: https://pubmed.ncbi.nlm.nih.gov/32822667/

Najm, H. K., et al. (2023). Surgical pearls of the transconal unroofing procedure—modifications and midterm outcomes. Annals of Thoracic Surgery. Available at: https://www.annalsthoracicsurgery.org/article/S0003-4975(22)00641-5/fulltext

Cleveland Clinic. (2023). New pearls and outcomes for transconal unroofing procedure. Consult QD. Available at: https://consultqd.clevelandclinic.org/new-pearls-outcomes-for-transconal-unroofing-procedure

American Hospital Association. (2019). Unroofing of anomalous coronary artery. AHA Coding Clinic for ICD-10-CM/PCS, Second

Quarter 2019, pp. 13–14. Available at: https://www.findacode.com/newsletters/aha-coding-clinic/icd/unroofing-anomalous-coronary-artery-I062020.html

Paclitaxel-Coated Balloon PCI Coding: ICD-10-PCS New Technology Guidance

Mon, 06 Apr 2026 18:58:03 GMT

ICD-10-PCS Coding for Paclitaxel-Coated Balloons in PCI (New Technology Codes)

Overview of Paclitaxel-Coated Balloon Use in PCI

With the expansion of drug-coated balloon technology in coronary interventions, coders must understand how to correctly report Paclitaxel-coated balloon (e.g., AGENT) use during PCI. FY 2025 ICD-10-PCS updates introduced new technology codes to capture this treatment — but correct assignment requires careful attention to documentation and sequencing.

How Paclitaxel-Coated Balloons Are Used in Coronary Interventions

Paclitaxel-coated balloons (DCB) are used during PCI to deliver medication directly to the vessel wall to treat in-stent restenosis and maintain vessel patency.

ICD-10-PCS Coding Guidelines for Drug-Coated Balloons in PCI

Key Coding Principles:

Code the standard PCI separately using Table 027 (Dilation of Coronary Artery).
Assign an additional New Technology code from Table XW0 to capture the drug-coated balloon.
Do not assume drug-coated balloon use is included in angioplasty coding.

Coding Example: Paclitaxel-Coated Balloon PCI

Procedure: PCI with angioplasty of one coronary artery using a Paclitaxel-coated balloon.

Code Assignment:

02703ZZ — Dilation of coronary artery, one artery, percutaneous
XW0J3HA — Paclitaxel-coated balloon technology, one balloon into coronary artery, one artery, percutaneous approach, New Technology Group 10

Documentation and Query Considerations for Accurate Code Assignment

Clinical Indicators:

PCI performed with balloon angioplasty
Procedure note references drug-coated balloon use

Query:

Can you clarify whether a drug-coated balloon (e.g., Paclitaxel-coated balloon such as AGENT) was used during this procedure? If so, please specify the number of balloons utilized.

Options:

Paclitaxel-coated balloon used (specify number of balloons)
Standard balloon angioplasty only
Other (please specify)
Unable to determine

Jessica Lutz, MBA, RHIA, CCS
AHIMA Microcredential: Auditing: Inpatient Coding

Senior Consultant, Audit at UASI

Jessica Lutz serves as a Senior Consultant in Auditing at UASI and is recognized for her ICD-10-CM/PCS expertise and inpatient coding background. She shares coding tips from an auditor’s perspective, highlighting common pitfalls and practical ways coders and CDI teams can improve accuracy and documentation quality.

Works Cited

American Hospital Association. (2024). Paclitaxel-coated balloon coding guidance. AHA Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2024, p. 55.

Boston Scientific. (n.d.). AGENT drug-coated balloon inpatient ICD-10-PCS coding reference. Available at: https://www.bostonscientific.com/content/dam/bostonscientific/Interventional%20Cardiology/pdp/agent/IC-1986308-AA_AGENT%20Inpatient%20ICD10%20PCS%20Coding%20Reference_Final.pdf

Centers for Medicare & Medicaid Services. (2024). New Technology Add-on Payment (NTAP) information: MEARIS. Available at: https://mearis.cms.gov/public/publications/ntap/NTP241007T6YMA

U.S. Food and Drug Administration. (n.d.). Paclitaxel-coated balloons and stents for peripheral arterial disease. Available at: https://www.fda.gov/medical-devices/cardiovascular-devices/paclitaxel-coated-balloons-and-stents-peripheral-arterial-disease

Welcome Elspeth Alston

Mon, 06 Apr 2026 13:06:32 GMT

UASI announces the addition of Elspeth Alston, CPC, as Education and Quality Manager

Elspeth brings more than 25 years of revenue cycle experience, specializing in professional fee coding, auditing, and education, with a strong focus on driving coding accuracy and sustainable performance improvement.

She joins UASI following a long tenure at Brault, where she held multiple leadership roles overseeing large coding teams, vendor partnerships, and quality initiatives. Known for her expertise in ICD-10 and CPT, Elspeth combines deep subject matter knowledge with a data-driven approach to help organizations achieve and sustain 95%+ accuracy while fostering a culture of continuous learning.

In her role at UASI, Elspeth will lead education and quality initiatives, supporting both internal teams and client engagements with a focus on strengthening coding accuracy, audit readiness, and long-term performance consistency.

“Elspeth’s ability to connect education, quality, and operations makes her an incredible asset to our team,” said Autumn Reiter, Chief Strategy and Solutions Officer at UASI. “Her experience driving measurable improvement will have a meaningful impact for our clients.”

Elspeth’s addition reflects UASI’s continued investment in experienced leadership and its commitment to delivering high-quality, results-driven solutions for healthcare organizations nationwide.

CDI & Coding Assessment Series: 8 Key Takeaways from the Poll Data

Fri, 27 Mar 2026 16:48:42 GMT

CDI & Coding Assessment Series: 8 Key Takeaways from the Poll Data

Our CDI & Coding Assessment LinkedIn poll series pointed to a familiar reality: most organizations are not in crisis, but they are not operating at a highly optimized level either. The results show programs with solid foundations, but also clear gaps in consistency, efficiency, and actionability.

1. Policy consistency is far from universal.

When we asked whether policies are clear, current, and consistently followed, the responses were split: 28% said policies are not clear or are outdated, 16% said they are only somewhat clear, and just 28% said they are fully clear and consistent. That means a majority of respondents stopped short of saying their policies are truly strong and consistently applied. For most organizations, policy infrastructure still has room to mature.

2. “Mostly clear” policies still create operational risk.

Another 28% selected “mostly clear and followed,” which sounds decent at first glance, but “mostly” is often where variation creeps in. In Coding and CDI, that usually means teams are not always interpreting guidance the same way, which can lead to rework, inconsistent documentation review, and avoidable compliance exposure.

3. Workflow friction appears to be widespread.

The workflow and throughput poll was one of the clearest signals in the series. 100% of respondents landed in the bottom two categories , and every single vote fell into “some inefficiencies.” Even with a small response count, that result is striking. It suggests bottlenecks, handoff issues, and process drag are not isolated problems. They are a normal part of operations for many teams.

4. High-efficiency workflows are still aspirational for many programs.

Not a single respondent selected “mostly efficient” or “highly efficient.” That tells us many organizations may have learned to function around inefficiencies instead of fixing them. Teams can still perform under those conditions, but delays in routing, review, escalation, or follow-up almost always affect productivity, turnaround time, and ultimately revenue performance.

5. Risk identification is still more reactive than proactive.

When we asked whether organizations proactively identify issues like modifier risk, DRG shifts, TEFRA compliance concerns, or payer trends, 56% said they are very reactive and another 33% said they have limited proactivity. That means nearly 9 in 10 respondents are operating without a strongly proactive risk model. For many organizations, problems are still being discovered after they have already affected performance.

6. True proactivity remains uncommon.

Only 11% of respondents said they are generally proactive , and 0% selected highly proactive. That matters because the strongest Coding and CDI programs do not rely on retrospective cleanup alone. They use trending, monitoring, and focused review to catch issues earlier. The poll suggests that level of maturity is still the exception rather than the norm.

7. KPI reporting exists, but actionability is limited.

The data and reporting poll showed a familiar middle-ground pattern. 60% said they have some useful metrics but limited impact, while only 20% said their KPIs are highly actionable. That tells us dashboards and reports may be present, but they are not always helping leaders make clear operational decisions. A metric is only valuable if it points to action.

8. The biggest theme across the series is middle-tier maturity.

Across the polls, the responses consistently clustered in the lower-middle or middle categories. Organizations are not saying everything is broken, but they are also not describing highly efficient workflows, highly proactive risk identification, or highly actionable reporting. That middle ground is important because it is exactly where hidden inefficiencies, compliance vulnerability, and missed financial opportunity tend to accumulate.

The Bottom Line

The poll series suggests that many Coding and CDI programs have the right building blocks, but those pieces are not yet working together at a high level. Policies may exist, workflows may function, risks may eventually be caught, and KPIs may be tracked, but the real opportunity is turning those separate efforts into a more consistent, proactive, and decision-driving program.

Risk Adjustment Is Becoming a Hospital Strategy & Not Just a Payer Function

Thu, 26 Mar 2026 18:36:19 GMT

Why Risk Adjustment Is Becoming a Hospital Strategy & Not Just a Payer Function

For years, risk adjustment has largely been viewed as a payer-driven exercise anchored in CMS-HCC models and primarily managed by health plans and primary care networks. Hospitals, by contrast, have traditionally focused on documentation through the lens of coding accuracy, DRGs, and retrospective CDI workflows. That division is starting to change.

As hospitals assume greater financial risk through Medicare Advantage, ACO participation, and employed physician networks, risk adjustment is becoming a core component of hospital strategy. Accurate longitudinal documentation now directly influences financial performance, population health insights, and the organization’s ability to compete in value-based models. It is increasingly becoming a shared responsibility and a strategic opportunity for hospitals themselves.

This shift is occurring alongside greater model complexity, including the transition to CMS-HCC V28, increased specificity requirements, and heightened audit scrutiny. Together, these forces place new pressure on hospitals to understand risk adjustment not as an abstract score, but as an operational and clinical documentation discipline. At the center of that shift is a familiar but evolving challenge: how well organizations capture and reflect the full clinical complexity of their patient populations over time.

The Gap Between Clinical Reality and Longitudinal Documentation

Hospitals generate a vast amount of clinical data, but much of it is episodic. Risk adjustment, however, is inherently longitudinal. It depends on consistent, year-over-year documentation of chronic conditions which is something that’s not always aligned with how inpatient and outpatient workflows operate and this creates a gap.

Patients with complex chronic conditions may receive appropriate care, yet their full clinical picture is not consistently reflected across encounters. Conditions that were documented one year may not be captured the next. Others may be treated but not explicitly documented in a way that supports accurate risk representation.

The result is not simply a documentation gap but a true visibility gap.

Without a clear, patient-level view of historical and current condition capture, organizations can struggle to answer basic questions:

Which chronic conditions have not been recaptured this year?
Which patients have fallen out of the risk-adjusted population?
Where are documentation patterns inconsistent across providers or service lines?

These are not questions that traditional CDI workflows were designed to answer on their own.

Why Traditional Approaches Fall Short

Most CDI programs are built around encounter-based review. They are highly effective at improving documentation accuracy within a single admission or visit, but they are not always structured to track condition capture across time.

Similarly, many organizations still rely on manual processes, retrospective reviews, or disconnected reporting to monitor risk adjustment performance. These approaches can be resource-intensive and often provide insight too late to influence outcomes within the current reporting year.

As risk adjustment becomes more relevant to hospital strategy, this disconnect becomes more pronounced. What’s needed is better visibility into patterns of documentation over time.

A More Integrated View of Risk and Documentation

This is where newer approaches are beginning to reshape how organizations think about risk adjustment.

Rather than treating it as a separate function, leading organizations are starting to integrate risk visibility directly into documentation workflows to connect claims history, current encounters, and condition recapture opportunities at the patient level.

Tools like RAF Vue™ are designed to support this shift by providing a centralized view of:

Previously reported chronic conditions
Current-year documentation status
Potential gaps in condition recapture
Estimated and realized RAF score impact

These findings are not outliers. Across organizations, similar patterns emerge where chronic conditions are documented intermittently, care is delivered but not longitudinally represented, and missed opportunities are driven by lack of visibility rather than lack of care. Instead of relying solely on retrospective reporting, this type of insight allows teams to identify where documentation may not fully reflect patient complexity while there is still time to act.

Importantly, this is less about adding another layer of review and more about bringing clarity to existing workflows.

From Retrospective Correction to Proactive Insight

One of the most significant changes in how risk adjustment is being approached is the shift from retrospective correction to proactive identification. When organizations have visibility into which patients have not had key conditions documented during the current year, where annual wellness visits or follow-ups may be missing, and how RAF scores are trending across populations, they are better positioned to align documentation practices with actual clinical care. This shift does not replace the role of CDI but expands it by enabling a more forward-looking and comprehensive approach to documentation.

CDI teams, in collaboration with coding, quality, and ambulatory leaders, can begin to operate with a broader view of documentation. They can begin viewing it as a longitudinal representation of patient health rather than a reflection of a single encounter.

What the Data Is Starting to Show

When organizations examine condition recapture at scale, the findings are often revealing.

In one RAF Vue™ implementation, analysis of 48,000 patient records identified a risk-adjusted population of approximately 3,500 patients, uncovering clear gaps in longitudinal documentation. Many chronic conditions were not being recaptured annually, and more than 500 patients had not completed an annual wellness visit during the current year.

The financial implications were significant, with over $24 million in potential opportunity tied to missed condition capture.

These patterns are not uncommon. They highlight how difficult it is to maintain consistent documentation across fragmented care environments, often due to limited visibility into patient risk over time.

The Growing Importance of Risk Adjustment for Hospitals

Risk adjustment is no longer just a back-office metric. It reflects the patients an organization serves and has become a strategic priority. It influences reimbursement, population health strategy, performance benchmarking, and financial planning. Organizations that align documentation with the full picture of patient complexity are better positioned to succeed.

At the same time, documentation is becoming more connected. Approaches like RAF Vue™ provide clearer visibility into the patient story over time, helping identify gaps in condition capture and enabling teams to work from a shared understanding of patient risk. This shift enhances existing workflows and reinforces risk adjustment as a core part of how hospitals represent the patients they serve.

Jessica Burrell, CPC, CRC, CDEO

Managing Consultant, Risk Adjustment and Strategy

Why Risk Adjustment Documentation Must Withstand False Claims Act Scrutiny

Tue, 17 Mar 2026 14:42:04 GMT

Why Risk Adjustment Documentation Must Withstand False Claims Act Scrutiny

Risk Adjustment Is Now a Compliance Issue

Risk adjustment has evolved beyond a financial strategy into a core compliance concern. Under the False Claims Act (FCA), unsupported or inaccurately reported diagnoses can lead to audits, retrospective recoupments, penalties, and reputational risk. As scrutiny increases, organizations must ensure that every reported condition is supported by clear, current, and clinically valid documentation and not just assumed accuracy.

Recent enforcement activity reinforces this shift. For example, Aetna recently reached a settlement related to allegations of overpayments tied to overcoding and overreporting in its Medicare Advantage plan highlighting how risk adjustment practices are increasingly being evaluated through a compliance and legal lens.

Unsupported HCCs Increase FCA Exposure

Hierarchical Condition Categories (HCCs) are essential to risk adjustment, but they also create compliance exposure when documentation does not support them in the current year. Diagnoses that lack clinical validation, specificity, or evidence of active management may be interpreted as false claims. Common risk areas include carried-forward conditions, incomplete documentation, and missing linkage between diagnosis and care. In these scenarios, documentation is the primary defense for organizations.

Overstated Risk Scores Lead to Financial Risk

When risk scores are inflated due to unsupported diagnoses, overpayments can occur. If those diagnoses cannot be substantiated during an audit, repayment demands and penalties often follow. As seen in cases like Aetna, these financial impacts do not always stop at the payer level. Repayment and audit pressure can extend downstream to providers, along with increased scrutiny and potential contractual exposure.

Model Changes Are Raising the Stakes

The transition from V24 to V28 and other model updates have increased the level of specificity required for accurate reporting. These changes reduce tolerance for vague or incomplete documentation and make it more difficult to defend reported conditions without detailed clinical support. As a result, organizations that fail to adapt their documentation practices face greater audit vulnerability.

Data Gaps and Variability Create Exposure

In addition to appropriate documentation practices, defensible risk adjustment depends on alignment across EHRs, claims, and analytics systems. When data is fragmented, organizations struggle to validate diagnoses and respond to audits efficiently. At the same time, variability in provider documentation creates inconsistent risk profiles, making it easier for auditors to identify patterns of potential noncompliance.

Audit Readiness Requires Clear Evidence

Audit readiness depends on the ability to produce traceable, contemporaneous documentation supporting each reported condition. This includes evidence of evaluation, monitoring, or treatment, along with specificity that aligns with current model requirements. Without this level of support, even clinically accurate diagnoses may not be considered compliant.

FCA risk is not about intent, it is about whether documentation can withstand scrutiny. Organizations must ensure that risk scores accurately reflect the care delivered and that every reported condition is fully supported. Strengthening documentation practices is essential to reducing audit exposure, maintaining compliance, and protecting revenue integrity.

Jessica Burrell, CPC, CRC, CDEO

Managing Consultant, Risk Adjustment and Strategy at UASI

Works Cited:

U.S. Department of Justice. Aetna Agrees to Pay $117.7 Million to Resolve False Claims Act Allegations. Available at: https://www.justice.gov/opa/pr/aetna-agrees-pay-1177-million-resolve-false-claims-act-allegations

U.S. Department of Justice. The False Claims Act: A Primer. Available at: https://www.justice.gov

ICD-10-CM and ICD-10-PCS Changes for April 1, FY 2026

Mon, 16 Mar 2026 18:01:31 GMT

ICD-10-CM and ICD-10-PCS Coding Updates Effective April 1, 2026

Overview of the April 1 ICD-10-CM and MS-DRG Updates

The release of updates for ICD-10-CM and for grouper V43.1 are now available from CMS and the CDC. The new updates will take effect on April 1,2026. Let’s break down three important changes for the CDI professional.

ICD-10-CM Index Update: Parkinson’s Disease Coding Revision

The release of the April 1, ICD-10-CM update includes a significant revision affecting how Parkinson’s disease is indexed. A new subterm “Parkinson’s disease – see Disease, Parkinson’s” has been added under the main term Parkinsonism, along with a new subterm “due to.” Additionally, the previous main term “Parkinson’s disease, syndrome, or tremor – see Parkinsonism” has been deleted and replaced with two clearer, more specific main terms:

Parkinson’s disease – See Diseases, Parkinson’s
Parkinson’s syndrome or tremor – See Parkinsonism

Why this matters : A documented diagnosis of Parkinson’s disease will now direct coders to G20.A1, rather than the former path that led to G20.C. This distinction improves clinical specificity but makes accurate provider terminology more critical than ever.

CDI Takeaways:

Parkinsonism and Parkinson’s disease are not interchangeable—verify that documentation reflects the correct diagnosis.
Look for causal language such as “due to meds,” “vascular,” or “secondary to…” to support appropriate code assignment.
Query when documentation is vague (e.g., “Parkinsonian features,” “Parkinsonism”) and clinical indicators support confirmed Parkinson’s disease.
Treatment clues such as levodopa/carbidopa may support clarification.
The updated indexing impacts severity capture and risk adjustment, making specificity essential.

ICD-10-CM Update: Respiratory Failure Excludes1 Note Changed to Excludes2

In Chapter 10 (J00–J99) Diseases of the Respiratory System, a key revision has been made involving respiratory failure coding. The Excludes1 note that previously prevented assigning J96.- Respiratory failure, not elsewhere classified alongside J95.82 Postprocedural respiratory failure has been changed to an Excludes2 note.

What this means : Clinically appropriate cases may now report both J96.- and J95.82 together, allowing more accurate capture of situations where a patient has pre-existing acute/chronic respiratory failure and develops postprocedural respiratory failure during the same admission.

CDI Takeaways:

Ensure the provider clearly documents timing: Was respiratory failure present prior to surgery, or did it arise after a procedure?
Look for clinical indicators that support dual diagnoses, such as baseline hypoxemia, NIV use, reintubation, increased ventilatory support, or ABG changes.
Query when documentation is vague (e.g., “respiratory failure” in a postop patient without clarification).
Distinguish between postoperative respiratory insufficiency and postoperative respiratory failure—they are not interchangeable.
Remember that accurate documentation of both types of respiratory failure may impact PSI-09, SOI/ROM, and overall severity capture.

ICD-10-CM Index Update: Neuroendocrine Tumor Coding Change

A notable ICD-10-CM update affects code assignment for neuroendocrine tumors. The Index entry previously directing coders from the terms “Tumor” and “neuroendocrine” to D3A.8 Other benign neuroendocrine tumors has been revised. The Index now points to C7A.- Malignant neuroendocrine tumors.

Why this matters: Codes in category C7A.- are CCs, whereas D3A.8 is not. This update means documentation that indexes to neuroendocrine tumors will now capture a CC, improving severity and accuracy in reporting when clinically appropriate.

CDI Takeaways & Tips:

Verify provider intent: benign vs. malignant.
The term “neuroendocrine tumor” can represent a spectrum—from benign NETs to malignant neuroendocrine carcinomas.
If the provider’s intent is unclear, a query may be required.
Confirm whether the tumor represents a malignancy, carcinoma, or low-grade malignant NET, as this affects correct C7A.- assignment.
Watch for grade, differentiation, and terminology changes. Providers may use terms such as:
“well-differentiated NET”
“Carcinoid tumor”
“Neuroendocrine carcinoma (NEC)"
These phrases may indicate malignant behavior even if “malignant” is not explicitly stated.
Review pathology reports carefully.
Pathology often determines tumor behavior. Look for descriptors such as:
Low-, intermediate-, or high-grade
Ki-67 index
mitotic rate
If pathology confirms malignancy but the operative/progress notes do not reflect it, consider sending a query.
Distinguish primary vs. metastatic sites.
C7A.- codes require identification of the primary site when possible.
If documentation only lists a “neuroendocrine tumor” of a secondary location (e.g., liver), verify whether there is:
A known primary tumor OR
True primary hepatic NET (rare)

Alyce Reavis, RN,MSN,CCDS,CCS

Senior CDI Educator, Consulting Services at UASI

Works Cited

Centers for Medicare & Medicaid Services. (2026). ICD-10 MS-DRGs Version 43.1 effective April 1, 2026. Available at: https://www.cms.gov

Greenwood, C. (2026). ICD-10-CM code updates – April 1, 2026. hiacode Industry News. Available at: https://hiacode.com/blog/icd-10-cm-code-updates-april-1

Fontan Physiology Complications

Wed, 04 Mar 2026 17:13:01 GMT

Fontan Physiology Complications and ICD-10-CM Coding

Overview of the Fontan Procedure and Fontan Physiology

The Fontan procedure (Fontan circulation) is performed in pediatric patients with single-ventricle congenital heart defects such as Tricuspid atresia, Hypoplastic left heart syndrome, and Double outlet right ventricle.

The altered “Fontan physiology” (chronic venous hypertension and low cardiac output) can result in long-term systemic complications affecting the liver, lymphatic system, and overall circulation.

ICD-10-CM Coding for Fontan-Associated Conditions

Use category I27.84- to report complications specific to Fontan physiology:

I27.840 – Fontan-associated liver disease (FALD)
I27.841 – Fontan-associated lymphatic dysfunction
I27.848 – Other Fontan-associated condition
I27.849 – Fontan-related circulation, unspecified

Coding Guidance

Code the specific Fontan-associated complication when documented.

I27.840 (FALD), FALD may include:

Liver fibrosis or cirrhosis
Regenerative arterialized liver nodules
Hepatocellular carcinoma
Code additional diagnoses (e.g., cirrhosis, hepatocellular carcinoma) as applicable.

I27.841 (Lymphatic dysfunction), Manifestations may include:

Plastic bronchitis
Protein-losing enteropathy
Report additional codes for the specific manifestations when documented.

I27.848 Other Fontan-associated condition, examples may include:

Arrhythmias
Ventricular dysfunction
Organ fibrosis

I27.849 Fontan related circulation, unspecified

Use when documentation states “Fontan-related circulation” without further detail.

Lori Amende, RHIA, CCS

Education and Quality Manager at UASI

Works Cited

American Hospital Association. (2025). Fontan-associated complications coding guidance. AHA Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2025, p. 19.

Children’s Hospital of Philadelphia. (n.d.). Hypoplastic left heart syndrome (HLHS). Available at: https://www.chop.edu/conditions-diseases/hypoplastic-left-heart-syndrome-hlhs

Leeds Teaching Hospitals NHS Trust. (n.d.). Fontan circulation. Available at: https://www.leedsth.nhs.uk/patients/resources/fontan-circulation/

Cerebral Edema: Types, Treatment, and Coding Considerations

Tue, 24 Feb 2026 14:44:33 GMT

Cerebral Edema ICD-10-CM Coding: Traumatic vs. Nontraumatic Distinctions

Overview of Cerebral Edema

Cerebral edema is a life-threatening condition that develops because of an inflammatory reaction. Most frequently, this is the consequence of cerebral trauma, massive cerebral infarction, hemorrhages, abscess, tumor, allergy, sepsis, hypoxia, and other toxic or metabolic factors.

Types of Cerebral Edema and Associated Codes

There are several types of cerebral edema:

Vasogenic cerebral edema G93.6
Cytotoxic cerebral edema G93.6
Hydrostatic cerebral edema G93.6
Traumatic cerebral edema S06.1Xxx
Interstitial cerebral edema G93.6

Each of the above can be caused by various scenarios that the attending or consulting Neurologist/Neurosurgeon will typically elaborate upon. Some physicians will differentiate ischemic cerebral edema usually resulting from traumatic incidents.

Clinical Management and Monitoring

Typically, these patients are monitored in an intensive care unit

These are just a few non-invasive treatments.

Tilting of the patient’s head to approximately 30 degrees, there are times when hyperventilation should be utilized and ensuring the patient’s volume status is slightly positive. Physicians may also use various pharmacological methods.

Invasive Treatment Options

Unilateral/bilateral decompressive craniotomies. These can include craniotomies of the posterior and lateral fossa.

Treatment of cerebral edema can be very complex and should be performed in a timely fashion to ensure the most positive outcomes.

Practical Coding Tip: Applying Cerebral Edema Documentation

When reviewing documentation for cerebral edema, focus on identifying:

The underlying cause (trauma, infarction, tumor, hemorrhage, infection, etc.)
Whether the edema is traumatic (S06.1Xxx) or non-traumatic (G93.6)
If decompressive craniotomy or other surgical intervention was performed
Documentation supporting ICU-level monitoring or aggressive management

If documentation does not clearly specify traumatic versus non-traumatic cerebral edema, a query may be appropriate to ensure correct code assignment. Remember that cerebral edema may be integral to certain conditions (such as traumatic brain injury), so clinical context is essential before assigning a separate code.

Jane Keesler, AA, CCS

Senior Consultant

Jane Keesler is a Senior Consultant at UASI, with a background in Inpatient, Outpatient, Hospice, Home Health, Dental, DME coding, DRG/APC validation, and HIM auditing across complex hospital cases. She shares clear, practical coding tips grounded in real audit findings to help coders strengthen accuracy, defensible DRG assignment, and compliant documentation.

Works Cited:

StatPearls Publishing. (2023). Cerebral edema. Available at: https://www.ncbi.nlm.nih.gov/books/NBK537272/

New Technology Code for Capsule Detection of Upper GI Bleed

Tue, 24 Feb 2026 14:33:31 GMT

Technology Code for Capsule Detection of Upper GI Bleed

Overview of the PillSense Capsule Technology

Rapid identification of gastrointestinal bleeding is essential for accurate diagnosis and timely clinical management. The PillSense capsule enables reliable detection of upper gastrointestinal bleeding in less than 15 minutes.

The PillSense system consists of a single-use, ingestible capsule and an external real-time receiver and does not require special patient preparation. The wireless capsule employs spectrophotometry—measuring light absorption across multiple visible wavelengths—to analyze gastric contents for the presence or absence of blood. The patient swallows the capsule with water and then lies on their left side while the external receiver remains nearby. Within approximately 10 minutes, the receiver displays one of two results: “Blood Detected” or “No Blood Detected.” The capsule is naturally excreted through the digestive process.

Documentation Terminology to Look For

Provider documentation identifying this procedure may reference the PillSense system, GI bleed detection capsule, blood detection capsule, or similar terminology.

ICD-10-PCS Code Assignment (Effective October 1, 2025)

Effective October 1, 2025, assign New Technology code XDJ07LB – Inspection of Upper Intestinal Tract using Ingestible Capsule with Light Absorption Sensor, Via Natural or Artificial Opening, New Technology Goup 11, for the PillSense Ingestible Wireless Capsule.

Practical Coding Tip: Applying the New Technology Code

When reviewing documentation for suspected upper GI bleeding, verify whether the provider is describing diagnostic visualization (such as endoscopy) or specifically referencing an ingestible capsule system like PillSense. The terminology may vary, so carefully review the procedure description for references to capsule ingestion, spectrophotometry, light absorption detection, or real-time external receiver results.

Key points to confirm in the documentation:

The procedure involves an ingestible capsule used for upper GI bleed detection
The capsule uses light absorption or spectrophotometry technology
The procedure is diagnostic inspection, not therapeutic intervention
The capsule system corresponds to the PillSense technology described

If these elements are present, assign XDJ07LB – Inspection of Upper Intestinal Tract using Ingestible Capsule with Light Absorption Sensor, Via Natural or Artificial Opening, New Technology Group 11.

If documentation is unclear regarding the type of capsule used or the technology applied, consider a query to ensure accurate assignment of the New Technology code.

Annette Brehl, RHIA, CCS, CCS-P

Senior Consultant, Quality

Annette Brehl is an Inpatient Coding Auditor and Educator at UASI, known for elevating coding quality through in-depth documentation analysis, a strong command of regulatory and coding guidelines, and targeted education. She shares coding tips informed by audit findings that help coders strengthen their accuracy, consistency, and confidence.

Works Cited:

Centers for Medicare & Medicaid Services. (2025). ICD-10 Coordination and Maintenance Committee Meeting Materials, Spring 2025: ICD-10-PCS Topic Slides. Available at: https://www.cms.gov/medicare/coding-billing/icd-10-codes/icd-10-coordination-maintenance-committee-materials/2025-03-14-icd10-meeting-materials

American Hospital Association. (2025). New technology code for ingestible capsule GI bleed detection. AHA Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2025, pp. 68–69.

Managing Risk in the Mid-Revenue Cycle: When Staffing Helps & When Another Solution is Needed

Wed, 11 Feb 2026 18:23:34 GMT

Managing Risk in the Mid-Revenue Cycle: When Staffing Helps and When Another Solution is Needed

How health system leaders reduce variability, protect margin, and avoid surprises

The mid-revenue cycle is one of the most significant sources of financial risk in healthcare. Performance depends on streamlined, collaborative workflows and the right tools to ensure documentation quality, coding consistency, and manage volume volatility.

Traditionally hospitals address this risk with hybrid workforce models: internal teams supported by external coders, CDI specialists, auditors, and denials resources. This approach is necessary and effective for maintaining throughput and continuity.

The strategic question executives are now asking is not whether to use staffing, but whether staffing alone is sufficient to manage risk. To answer that question, it helps to be clear about what staffing is designed to solve — and what it is not.

Staffing: Effective for Capacity Challenges

Staff augmentation is well-suited to mitigate capacity-driven risk. It helps organizations:

Maintain production during vacancies or leaves
Absorb volume swings and backlog pressure
Access specialized expertise

When risk is caused by insufficient coverage, whether short-term or longer, staffing is the right answer. Challenges emerge when capacity is no longer the primary constraint, but performance outcomes remain inconsistent.

Staffing often becomes the default solution. It’s familiar, safe, comfortable. But it is not designed to redesign workflows, strengthen collaboration, or drive ongoing optimization. By design, augmented resources operate within existing workflows, quality standards, and governance structures. As a result, risks and opportunities for improvement often persist.

What Staffing Doesn’t Solve:

Augmenting your staff solves capacity challenges, but doesn’t reveal risks that might exist such as:

Inconsistent coding and documentation interpretation
Preventable downstream denials caused by program breakdowns and educational needs
Cost structures tied to volume rather than performance
Leadership time consumed by operational oversight and not root cause problem resolution
Workflow inefficiencies

Capacity may be only one of your challenges. Your primary risk may not be rooted in having enough people, but how consistently the work is performed and the process in which you are performing it. When inconsistency and optimization becomes the dominant challenges, organizations often need a different operating approach.

Managed Services: A Solution for Variability and Optimization

Managed services addresses variability risk by shifting accountability from filling a seat to outcomes-based focus.

Rather than just supplying capacity, a managed services partner provides:

Standardized quality and accuracy frameworks
Consistent guideline application across teams
Embedded governance and performance transparency
Continuous optimization as volumes and payer behavior change

For executives, this transforms the mid-revenue cycle from a staffing-dependent function into a more predictable and efficient operating model. At that point, the success of managed services depends as much on mindset as it does on structure and partnership.

Managed Services Works Best as an Operating Partnership

Managed services delivers the most value when it is approached as a long-term operating partnership, not a short-term solution. The goal is stability first, followed by sustained improvement as workflows, quality standards, and governance mature over time. Meaningful results are achieved through continuity, shared accountability, and a clear understanding that performance gains compound and create stability with time. They are not instantaneous. Organizations that are willing to embrace a long-term comprehensive approach are better positioned to realize consistent outcomes, improved predictability, and operational alignment. That said, managed services works for many organizations, but is not the only way to achieve greater discipline and visibility. Each facility has nuanced challenges where models and approaches depend on change management and goals.

Maintaining Control While Improving Transparency

While there are many benefits to a managed services partnership, many organizations choose to retain significant in-house ownership of mid-revenue cycle functions.

For those organizations the priority should be visibility and alignment. Periodic assessments, supported by regular audits provide objective insight into structure, workflows analysis, tools, and performance. These reviews are especially valuable when the organization undergoes change, such as a system implementation, workforce shift, or evaluation of new technologies like AI. A consistent assessment cadence keeps internal operations optimized, performance transparent, and leadership informed — reducing reliance on assumptions and enabling more confident decision-making. Ultimately, the right next step depends on the specific challenges an organization is trying to solve for.

Should I Take Any Action?

The answer is that it depends on the problem you are trying to solve and the risk you are mitigating. Staffing ensures coverage. Managed services ensure control and optimization.

Both play an important role — but they mitigate different types of risk.

As margin pressure intensifies, the most resilient organizations are aligning the right operating model to the right risk and managing the mid-revenue cycle with greater discipline and predictability. The most resilient organizations treat objective, periodic assessments as a core discipline, regardless of operating model."

Nancy Koors, MBA, MS, BS

Chief Executive Officer

New Prostate Biopsy CPT Codes Effective January 1, 2026

Tue, 10 Feb 2026 14:03:38 GMT

New Prostate Biopsy CPT Codes Effective January 1, 2026

Prostate Biopsy Approaches

Transperineal: Prostate biopsy performed through the perineum, with needle access obtained externally rather than through the rectum.
Transrectal: Prostate biopsy performed through the rectal wall, with needle access obtained transrectally to sample prostate tissue.

Imaging Guidance Used for Some Prostate Biopsies

Ultrasound: Using real-time imaging to guide biopsy tools to desired location
MRI Ultrasound-fusion: MRI images taken ahead of time are used with real-time ultrasound to see exact location of the target for biopsy
In-Bore CT or MRI guidance: used for needle placement access

Types of Prostate Biopsies

Sextant Biopsy: 6-12 core samples taken from different sections throughout the prostate, not often used anymore as it has a high-risk of missing the cancer.
Template Guided Saturation Sampling: Uses a template to take 20 or more samples of different regions of the prostate at one time. This takes more samples than the standard biopsy. This provides a wider selection of cells to test for cancer. Usually done in high-risk patients or when a clinical suspicion of cancer exists.
Lesion-Based Biopsy: The physician uses imaging to get biopsies of one or more lesions.
Report biopsies once per lesion; typically, multiple biopsies are taken from each lesion.
Use add-on code (55715) for additional lesions where biopsies are taken.

All new codes include imaging. A separate imaging code is not reported.

Practical Coding Application

When applying the new prostate biopsy CPT codes effective 1/1/26, focus on lesion-based reporting rather than the number of cores obtained. Multiple cores taken from the same lesion are reported once per lesion, regardless of how many samples are collected.

Key points to verify in the documentation:

The number of distinct lesions biopsied
Whether biopsies were performed on additional lesions requiring add-on code 55715
The approach used (transperineal or transrectal)
The type of imaging guidance documented, understanding that imaging is bundled into the new codes
If no specific lesion is biopsied, check documentation to see if template saturation biopsy was done

If the operative report does not clearly identify the approach, the technique and the number of lesions targeted (if applies), a query should be considered to support accurate CPT code assignment under the new guidelines.

Katie Brown, CCS

Senior Consultant, Audit at UASI

Works Cited

Cleveland Clinic. (n.d.). MRI-guided prostate biopsy. Available here: https://my.clevelandclinic.org/health/diagnostics/16382-mri-guided-prostate-biopsy

Hillman Cancer Center. (n.d.). Needle biopsy of the prostate. Available here: https://hillman.upmc.com/cancer-care/prostate/screenings/needle-biopsy

Large Urology Group Practice Association. (2025). Major CPT code changes ahead: What every urologist must know before January 2026. Available here: https://www.lugpa.org/index.php?option=com_content&view=article&id=785:major-cpt-code-changes-ahead--what-every-urologist-must-know-before-january-2026&catid=28:latest-news

MD Anderson Cancer Center. (n.d.). Prostate biopsy explained: Process, recovery, and results. Available here: https://www.mdanderson.org/cancerwise/prostate-biopsy-explained--process--recovery-and-results.h00-159701490.html

Outsource Strategies International. (n.d.). Urology medical billing and coding for prostate biopsies. Available here: https://www.outsourcestrategies.com/blog/urology-medical-billing-coding-prostate-biopsies/

How to Code Fibrin Sheath Disruption During Dialysis Catheter Procedures

Mon, 09 Feb 2026 17:57:19 GMT

How to Code Fibrin Sheath Disruption During Dialysis Catheter Procedures

What Is a Fibrin Sheath and Why Does It Cause Catheter Dysfunction?

Periodically, patients with dialysis or perma-catheter experience stenosis due to a fibrin sheath, which is a common complication of central venous catheters. A fibrin sheath is a “heterogeneous matrix of cells and debris that form around catheters,” essentially creating an adhesion-like barrier around the catheter.

This complication can cause stenosis and limit flow through the catheter, often resulting in the need for catheter replacement.

Clinical Overview: Fibrin Sheath Disruption and Catheter Replacement

The fibrin sheath must be disrupted or broken up to allow placement of a new catheter and remedy the stenosis and flow limitations caused by the extra lining in the vessel.

First, the current catheter must be removed. Then, a dilator is placed over a guidewire and the vessel and sheath are balloon dilated from the inside. This re-opens the vessel, allows passage and placement of a new catheter, and restores catheter function.

Coding Guidance for Disruption of a Fibrin Sheath

When “disruption of fibrin sheath” is documented, what is the correct coding?

Thankfully, we have Coding Clinic guidance (3rd Quarter 2018, page 10) for clarification. This Coding Clinic states that disruption of a fibrin sheath should be coded as a dilation of the vessel.

This code will be reported in addition to the catheter exchange code, if an exchange is also performed during the same encounter.

Coding Tip: Fibrin Sheath Disruption vs Thrombus Removal

When documentation states “fibrin sheath disruption,” “balloon disruption,” or “angioplasty of the fibrin sheath”, remember that this procedure is coded as venous angioplasty (dilation of the vessel), not as a thrombus removal or mechanical catheter complication.

Documentation Elements Needed for Accurate Code Assignment

To ensure accurate code capture, look for these key documentation elements:

Balloon dilation performed within the vein
Disruption of fibrin sheath to restore catheter function
Catheter exchange occurring in the same session (if applicable)
Coding Reminder:
Code the venous dilation/angioplasty plus the catheter exchange when both procedures are performed.

Kendra Adams, RHIT

Senior Consultant, Audit at UASI

With a background in health information technology and ICD-10 coding, Kendra Adams serves as a Senior Consultant in Audit at UASI. She contributes clear, practical coding tips rooted in real-world audit work to help coders improve accuracy, documentation quality, and compliant code assignment.

Works Cited

American Hospital Association. (2018). Disruption of fibrin sheath (venous dilation guidance). AHA Coding Clinic for ICD-10-CM/PCS, Third Quarter 2018, p. 10.

PubMed Central (PMC) . (2013). Fibrin sheath angioplasty: A technique to prevent superior vena cava stenosis secondary to dialysis catheters. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC3578630/

Renal Fellow Network. (2023). Disrupting catheter-associated fibrin sheath formation. Available at: https://www.renalfellow.org/2023/04/25/disrupting-catheter-associated-fibrin-sheath-formation/

Welcome Jessica Burrell

Tue, 03 Feb 2026 15:00:00 GMT

UASI Appoints Jessica Burrell as Managing Consultant, Risk Adjustment and Strategy

UASI is pleased to announce Jessica Burrell, CPC, CDEO, CRC, as Managing Consultant, Risk Adjustment and Strategy. Jessica brings more than 15 years of healthcare experience across risk adjustment, CDI, coding accuracy, compliance, and value-based care initiatives.

Jessica joins UASI with extensive leadership experience, most recently serving as Senior Client Coding Project Manager at Datavant, as well as Manager of Clinical Data Integrity at Apex Health Solutions and Director of CDI & Coding at Curation Health. Her professional background encompasses hands-on roles in coding, auditing, and compliance within multispecialty and managed care settings, affording her a comprehensive, end-to-end understanding of healthcare data integrity.

She holds CPC, CDEO, and CRC credentials through the American Academy of Professional Coders (AAPC) and is an active member of AAPC and the National Alliance of Medical Auditing Specialists.

In her new role at UASI, Jessica will focus on advancing risk adjustment and OP CDI strategy, strengthening provider and payer partnerships, and delivering scalable solutions that balance financial performance, quality outcomes, and regulatory oversight. She will also play a key role in expanding UASI’s consulting capabilities and technology-driven risk adjustment solutions, while helping clients navigate an increasingly complex value-based care landscape.

“Jessica’s depth of expertise, leadership experience, and passion for data integrity make her an exceptional addition to UASI,” said Autumn Reiter, Chief Strategy and Solutions Officer at UASI. “Her ability to align clinical accuracy with strategic outcomes will be instrumental as we continue to grow and evolve our risk adjustment and consulting services.”

Jessica’s appointment reflects UASI’s continued investment in senior leadership and its commitment to delivering trusted insights, operational excellence, and measurable results for clients nationwide.

When Was the Last Time You Pressure-Tested Your HIM Program?

Fri, 30 Jan 2026 17:05:02 GMT

When Was the Last Time You Pressure-Tested Your HIM Program?

The first quarter gives you time to “reset” and brings a new start and new perspective. Things feel under control – stable and achievable. Volumes are predictable, workflows are familiar, and performance metrics look consistent with expectations. For many HIM and compliance leaders, that stability is a sign the program is doing what it’s supposed to do. The challenge is that stability doesn’t always mean optimal performance. In fact, it often means “status quo”.

Strong Programs Drift—Even When Teams Are Doing the Right Things

Most HIM programs evolve continuously. Documentation habits shift, coding guidance changes, workforce changes are constantly happening in the revenue cycle and the clinical staff, payer behavior adapts, and automation alters how work gets done. These changes rarely feel disruptive in the moment. Teams adjust, workarounds are created and root causes of issues often go unnoticed.

Over time, though, those small shifts can pull a program away from how it was originally designed to operate. Not because anyone did something wrong—but because the work moved faster than the governance around it. Feel familiar? Many HIM Directors say “that sounds like my life.” This kind of drift is common. It’s also difficult to see from inside the program when dealing with the day-to-day.

Why Dashboards Don’t Always Answer the Right Questions

Operational reports and dashboards are essential, but they tend to answer narrow questions:

Are we meeting productivity targets?

Are quality scores within range?

Are denial rates stable?

What they don’t tell you is the whole story. In addition, they don’t consistently show is why performance looks the way it does—or how much manual effort, workaround, or risk is sitting beneath the surface to keep those metrics green.

Because reporting is often siloed by function, a holistic picture is difficult to see. Reporting often doesn’t show early signals of misalignment across documentation, CDI, coding, and denials which can remain invisible until something changes downstream.

Q1 Is the Easiest Time to Take an Objective Look

Later in the year, reviews are often triggered by a problem: a denial trend, an audit, a quality score shift, or regulatory scrutiny. By then, the conversation is about fixing, defending, or explaining.

Q1 offers a different opportunity.

Early in the year, HIM and compliance leaders can step back and ask a simpler question:

Does the way our program is operating today still match how we believe it’s operating and how we want it to operate?

A focused review isn’t about finding fault or identifying who is doing a bad job. It’s about establishing a clear baseline—what’s working as intended, where workflows have drifted, and where small adjustments now can prevent larger issues later.

Why This Matters for HIM and Compliance Leaders

When questions arise later in the year, they’re rarely framed around effort. They’re framed around outcomes. Leaders who have already evaluated their programs can speak confidently to what they know, what they’ve validated, and what they’ve proactively addressed. Those who haven’t stepped back to do an objective evaluation are often forced to rely on assumptions and high-level metrics that don’t tell the full story.

Taking time early in the year to independently evaluate program health isn’t a sign that something is wrong. It’s a sign of professional stewardship—one that protects revenue, teams, supports credibility, and reduces the likelihood of surprises when visibility increases later in the year.

Welcome Tanya Citron

Wed, 28 Jan 2026 13:49:57 GMT

UASI Welcomes Tanya Citron as Managing Consultant, Denials Management & Strategy

UASI is excited to welcome Tanya Citron, MBA, RHIA, as Managing Consultant, adding a strong operations-focused and analytics-driven perspective to the firm’s consulting leadership. Tanya brings extensive experience improving revenue integrity, operational performance, and enterprise-wide efficiency for healthcare organizations.

Tanya has more than 15 years of healthcare experience leading complex, cross-functional initiatives across consulting and provider environments. Most recently, she served as a Healthcare Managing Consultant at Berkeley Research Group, where she led multi-department revenue cycle initiatives that achieved a 30% reduction in pre-bill accounts receivable days, improved clean claim rates, reduced denials, and accelerated cash flow.

Previously, as a Healthcare Consulting Manager at Huron Consulting Group, Tanya led large-scale transformation initiatives aligned to client strategy, delivering substantial revenue capture improvements, meaningful efficiency gains, and significant reductions in accounts receivable. She is recognized for building strong client partnerships, leading high-performing teams, and mentoring consultants through complex engagements.

Tanya’s background also includes more than a decade at Northwest Community Healthcare, where she held leadership roles in physician network operations, revenue integrity, and compliance. Her experience spans managing contracts for physicians and vendorsrelationships, developing analytic dashboards, overseeing charge capture and reimbursement initiatives, as well as supporting payer and regulatory compliance efforts.

Tanya holds an MBA in Business Analytics from the University of Illinois at Urbana-Champaign and maintains her RHIA credential from AHIMA.

At UASI, Tanya will focus on helping clients improve financial and operational performance through practical, data-driven strategies related to denials management and strategy. She will drive organizational growth by driving organizational change and strengthening revenue integrity solutions while delivering sustainable improvements that align operational performance, compliance, and measurable outcomes.

Cerebral Palsy: Documenting Motor Type, Severity, and Coding Impact

Mon, 26 Jan 2026 14:10:23 GMT

Cerebral Palsy: Documenting Motor Type, Severity, and Coding Impact

Definition: Cerebral palsy (CP) describes a group of heterogeneous conditions that have lifelong impact on motor function, muscle tone, posture, and movement. This is due to the improper development of the fetal or infant brain. Motor function deficits can range in severity and are commonly accompanied by altered sensation, intellectual disability, seizures, and musculoskeletal complications.

Clinical Features and Indicators of Cerebral Palsy

Common Motor Function Features:

Muscle spasticity
Hyperreflexia
Clonus
Hypotonia
Ataxia

Common Clinical Indicators:

Abnormalities in motor activity and tone
Delay in meeting developmental motor milestones
Abnormal developmental reflexes
Feeding difficulty
Growth failure
Epilepsy

Cerebral Palsy Motor Phenotypes

Common motor phenotypes:

Spastic CP - Most common pattern of motor impairment, accounting for up to 85 percent of individuals with CP. These patients have clinical features of an upper motor neuron syndrome, including muscle hypertonia, hyperreflexia, extensor plantar responses, and clonus.
Dyskinetic CP - Indicates that dyskinesia such as dystonia or choreoathetosis (e.g., involuntary twitching) is the predominant pattern of abnormal tone.
Ataxic CP - Characterized by uncoordinated movements and speech, usually associated with widespread disorder of motor function. This type is rare.

ICD-10-CM Coding for Cerebral Palsy

CDI Documentation and Query Considerations

Thoughts for the CDI Professional

Intellectual disability is common in children with CP, 40-65%.
Documentation should indicate the degree of weakness or paralysis associated with CP and any intellectual disability with severity specified.

Sample CDI Query for Cerebral Palsy Specificity

Query Example:

Dr. _________

This patient has documentation and findings for cerebral palsy in the H&P from x/x.

Based on review of the clinical indicators presented, can this information be further specified? For example:

Spastic hemiplegic cerebral palsy
Other explanation of clinical findings (please specificity)

Additional supporting information from patient’s record:

Clinical Indicators:

Physical Exam notes left sided spasticity and increased tone and thin left upper extremity likely related to limitation of use.

Risk Factors:

Patient with neonatal asphyxia at birth

Monitoring/Evaluation and/or Treatment:

Continuation of PTA Baclofen
Recent injection of Botulinum toxin
PT/OT consult ordered

Thank you!

-CDI Specialist signature

Please use your independent professional judgment when responding. A question does not imply that a particular diagnosis is expected. Please update your last progress note and/or discharge summary to include the relevant diagnosis.

This query will become part of the patient’s permanent medical record.

Alyce Reavis, RN,MSN,CCDS,CCS

Senior CDI Educator, Consulting Services at UASI

Works Cited

Barkouda, E. (2025–2026). Cerebral palsy: Classification, clinical features, management, and prognosis. UpToDate. Available at: https://www.uptodate.com

Centers for Medicare & Medicaid Services. (2026). IPPS Final Rule. Available at: https://www.cms.gov

Pinson, R., & Tang, C. (2025). Cerebral palsy. Pediatrics by PRG from the CDI Pocket Guide. CDIPlus.

Sandifer Syndrome ICD-10-CM Coding Guidance

Mon, 26 Jan 2026 13:39:47 GMT

Sandifer Syndrome and ICD-10-CM: Coding GERD With Neuromuscular Symptoms

According to Cleaveland Clinic, “Sandifer syndrome is a condition that causes a baby to have uncontrollable muscle spasms after they eat. This happens because the baby has acid reflux and moves their body in different ways to ease the discomfort that they feel.” Seven percent of infants in the US experience GERD and less than 1% of those infants experience muscle spams (Sandifer Syndrome).

Clinical Presentation and Diagnostic Considerations

Symptoms that can trigger potential query for Sandifer Syndrome: post-feeding dystonic movements, neck twisting, arching, or muscle spasms in an infant with GERD. Sandifer syndrome symptoms my mimic seizure activity. Make sure to review any work-up.
Do not code Sandifer syndrome as a standalone condition or assume the diagnosis based solely on symptoms. Provider documentation must support GERD and the associated neuromuscular finding.
Symptoms are most common after the baby eats when the contents of their stomach haven’t settled.
Sandifer syndrome typically affects infants, young children and those with developmental delays.
Babies that experience this have symptoms that are equivalent to adult “heartburn”

Sandifer syndrome is a temporary condition that typically disappears by the time they reach one year old. Dietary changes, medications, keeping their head elevated while they eat and burping them during and immediately after they eat can all help reduce the symptoms.

ICD-10-CM Coding Guidance for Sandifer Syndrome

Code Assignment: Sandifer syndrome does not have a unique ICD-10-CM code. When documented, assign:

K21.9 – Gastro-esophageal reflux disease without esophagitis, and
An additional code for the associated manifestation (e.g., torticollis or muscle spasm), if separately documented and clinically evaluated.

Guidance from Coding Clinic, First Q 1995 page 7 directs us to capture GERD (K21.9) and Torticollis or muscle spasms documented in the chart.

Liz Burson, BS, CCS

Senior Consultant, Audit at UASI

Liz Burson serves as a Senior Consultant in Auditing at UASI, with 20+ years of outpatient and inpatient coding experience. She provides coding tips based on current audit findings to help coders improve their accuracy in capturing the correct ICD-10-CM and PCS codes.

Works Cited

Cleveland Clinic. (n.d.) . Sandifer syndrome: Symptoms, causes & outlook. Available at: https://my.clevelandclinic.org/health/diseases/sandifer-syndrome

American Hospital Association. (1995). Sandifer syndrome. AHA Coding Clinic for ICD-10-CM/PCS, First Quarter 1995.

Apnea of Prematurity CDI Tip

Tue, 13 Jan 2026 17:12:02 GMT

Apnea of Prematurity CDI Coding Considerations

What is apnea of prematurity?

A condition commonly associated with the newborn requiring NICU level of care. This is related to the immature development of the respiratory system. Severity and frequency are related to the gestational age. A large proportion of extremely preterm (<28 weeks GA) or have birthweight that is extremely low (<1000 grams) will demonstrate apnea of prematurity.

Clinical Indicators of Apnea of Prematurity

Apneic spells are typically defined as the cessation of breathing for >/= 20 seconds or longer. A shorter pause that is accompanied by hypoxia and/or bradycardia (<100 BPM), cyanosis or pallor also meets this threshold

Types of apnea of prematurity include:

Central – Defined by the cessation of breathing
Obstructive – Airflow is obstructed typically at the pharynx
Mixed – Describes the obstructed airflow leading to central apneic pause, or vice versa.

Mixed apnea comprises the majority of apneic episodes in preterm infants.

Treatment Approaches for Apnea of Prematurity

(May be selected based on gestational age and the severity of apnea)

Respiratory support is the focus
nCPAP
NIPPV
Mechanical ventilation
Methylxanthines (caffeine and theophylline)

Coding and CDI Considerations for Apnea of Prematurity

Subcategory P28.4-, Other apnea of newborn
These codes provide a CC/OSP (Other Significant Problem) and SOI of 2
When apnea is persistent and requires respiratory support listed in the treatments above, the CDS should review any indicators of respiratory failure.
It is appropriate to query if respiratory failure indicators unique to the newborn patient are identified.

Alyce Reavis, RN,MSN,CCDS,CCS

Senior CDI Educator, Consulting Services at UASI

Works Cited

Manz, J., Prescott, L. ACDIS CDI Pocket Guide. 2025. Apnea of Prematurity [Neonatal]. Pocket Resource Online.

Martin, R. Management of Apnea of Prematurity. UpToDate. May 30, 2025. Available at: https://www.uptodate.com/contents/management-of-apnea-of-prematurity

Zivaljevic, J., Jovandaric, M. Z., Babic, S., & Raus, M. Complications of Preterm Birth—The Importance of Care for the Outcome: A Narrative Review. Medicina. 2024;60(6):1014. Available at: https://doi.org/10.3390/medicina60061014

Adverse Effects vs. Poisoning in ICD-10-CM (T36–T50)

Tue, 13 Jan 2026 15:41:11 GMT

Adverse Effects vs. Poisoning in ICD-10-CM
(T36–T50)

Why do we need to know this? There are different sequencing rules for each. ICD-10-CM guidelines provides greater detail in defining each term and providing examples. The same drug and same symptoms may appear in both categories — the difference is how the substance was used.

Adverse Effect Coding Guidelines and Sequencing

Definition -A reaction occurs when the correct drug is:

Prescribed correctly
Administered correctly
Taken as directed

Sequencing -Nature of the adverse effect:

Tachycardia
Delirium
GI hemorrhage
Vomiting
Hypokalemia
Hepatitis
Renal failure
Respiratory failure

T36–T50 code with 5th/6th character “5”

Example: Patient took her prescribed dose of penicillin and has severe nausea and vomiting. Physician final diagnosis is nausea and vomiting due to adverse effect of penicillin.

R11.2 Nausea with vomiting
T36.0X5A Adverse Effect of Penicillin, initial encounter

Key Indicator: Everything about the drug use was correct — the reaction is the issue.

Poisoning Coding Guidelines and Sequencing

Definition - The substance was used incorrectly in any way.

Examples of Poisoning Scenarios

Prescription error
Wrong drug taken
Wrong route
Overdose (intentional or unintentional)
Taking someone else’s medication
Nonprescribed drug taken with a prescribed drug
Drug–alcohol interaction

Sequencing- Poisoning code (T36–T50) first, using correct intent character:

1 = Accidental
2 = Intentional self-harm
3 = Assault
4 = Undetermined
If intent unclear → default to accidental

All manifestations next

Seizures
Hypotension
Altered mental status

Example: Patient comes in with altered mental status. He states he accidentally took two OxyContin tablets at the same time instead of one as prescribed.

T48.0X1A Poisoning by oxytocic drugs, accidental (unintentional), initial encounter
R41.82 Altered mental status

Key Indicator: Something about the drug use was incorrect, regardless of symptoms.

Quick Coding Memory Rules for Adverse Effects vs. Poisoning

Quick Memory Rules

Adverse Effect:
Reaction first → drug second
Correct use = adverse effect

Poisoning:
Drug first → reaction second
Incorrect use = poisoning

Documentation Focus Points for Accurate Drug Coding

Was the drug used as prescribed or incorrectly?
Was there an error, overdose, or interaction?
What manifestations occurred?
Is the intent documented?

Melanie Perrault, RHIA, CDIP, CCS

Senior Consultant, Audit at UASI

Works Cited

American Hospital Association. AHA Coding Handbook for ICD-10-CM and ICD-10-PCS. 2026. Chapter 31: Poisoning, Toxic Effects, Adverse Effects, and Underdosing of Drugs. Available here: https://www.aha.org/coding-clinic/coding-handbook

Centers for Disease Control and Prevention, National Center for Health Statistics . ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026. Chapter 19: Injury, Poisoning, and Certain Other Consequences of External Causes (S00–T88), Section on Poisoning, Adverse Effects, and Underdosing (T36–T50). Available here: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2026/ICD-10-CM-October-2025-Guidelines.pdf

American Academy of Professional Coders (AAPC) . Verhovshek, J. Poisoning, Adverse Effect, and Underdosing in ICD-10-CM.
Available here: https://www.aapc.com/blog/44094-poisoning-adverse-effect-underdosing-icd-10/

Using Radiology to Improve Ischemic Stroke (CVA) Coding Specificity

Wed, 07 Jan 2026 19:43:48 GMT

Using Radiology to Improve Ischemic Stroke (CVA) Coding Specificity

Why Radiology Matters in Ischemic Stroke Coding

Once a provider has diagnosed an acute ischemic stroke or cerebral infarction, coders may use radiology reports interpreted by a physician to support:

Location of artery involved
Laterality
Confirmation of infarction

This approach is supported by long-standing AHA Coding Clinic guidance, which allows use of diagnostic studies to provide specificity after the diagnosis itself has been established.

However, radiology has limits.

Important Clarification: What Radiology Can and Cannot Support

Radiology may support where the infarction occurred, but it cannot be used to infer mechanism unless the provider documents it.

AHA Coding Clinic, First Quarter 2024 reinforced this principle by clarifying that:

Identifying an artery alone (e.g., posterior cerebral artery territory) does not justify assigning a mechanism-specific code
When occlusion, stenosis, embolism, or thrombosis is not documented, coders must not assume the cause

In these cases, the infarction may still be coded with location specificity when supported — but mechanism-based I63 subcategories require explicit documentation.

Practical Coding Guidance for CVA Documentation

Use radiology to support location and laterality
Assign mechanism-specific I63 codes only when documented
Do not infer occlusion, embolism, stenosis, or thrombosis from imaging alone
Do not default to I63.9 if location is clearly supported but mechanism is not required for the selected code

CVA Coding Example Using Radiology Findings

Discharge Summary: “Acute ischemic stroke.”
MRI Brain: “Acute infarct involving the left middle cerebral artery territory.”
No documentation of occlusion, stenosis, embolism, or thrombosis.
Correct Coding: I63.89 — Other cerebral infarction
Radiology supports location, but without documented mechanism, a mechanism-specific MCA code is not appropriate.

Why Accurate Use of Radiology Matters for CVA Coding

Encourages appropriate specificity without overcoding
Reduces unnecessary use of I63.9 when location is documented
Prevents audit risk from inferred mechanisms
Aligns coding with both historic and current Coding Clinic guidance

When to Query the Provider for Stroke Documentation

A query should be considered when:

CVA is referenced during the stay but not addressed at discharge
Imaging identifies a specific artery, but the diagnosis is unclear
Conflicting documentation exists regarding stroke type or etiology

Documentation Accuracy and Audit Risk Considerations

Correct application of this guidance:

Prevents inappropriate use of I63.9 when specificity is supported
Maintains compliance with uncertain diagnosis rules
Improves data accuracy, SOI/ROM capture, and audit defensibility

The key distinction is diagnosis vs. specificity — imaging can support the latter, but never establish the former.

Bonus Coding Tip: NIH Stroke Scale (NIHSS)

When an acute CVA is documented, review the record for an NIH Stroke Scale (NIHSS) score. NIHSS may be reported as a secondary code when documented by a provider during the inpatient stay.

Code category: R29.7
Assign the code based on the final NIHSS score documented
NIHSS does not need to appear in the discharge summary if clearly documented elsewhere in the record
If multiple scores are documented, report the initial score (facilities may choose to capture multiple scores)
NIHSS can be captured from documentation by clinicians other than the patient’s provider

Example: NIHSS score of 8 → R29.708

Capturing NIHSS improves stroke severity reporting and supports a more complete clinical picture.

Jessica Lutz, MBA, RHIA, CCS
AHIMA Microcredential: Auditing: Inpatient Coding

Senior Consultant, Audit at UASI

Works Cited:

Centers for Disease Control and Prevention. (2024). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2025: Section II.H. Available at: https://www.cdc.gov/nchs/data/icd/10cmguidelines-FY2025.pdf

American Hospital Association. (2014). Cerebral infarction coding guidance. AHA Coding Clinic for ICD-10-CM, Third Quarter 2014.

American Hospital Association. (2024). Radiology documentation and cerebral infarction specificity. AHA Coding Clinic for ICD-10-CM, First Quarter 2024.

The Haugen Group. (n.d.). ICD-10-CM stroke coding: The why behind the codes (Webinar Q&A). Available at: https://www.thehaugengroup.com/cm-stroke-coding-q-a/

Arizona Health Information Management Association (AzHIMA). (2025). Unlocking the full potential of stroke coding and documentation. Available at: https://www.azhima.org/annualmeeting/wp-content/uploads/2025/06/Unlocking-the-Full-Potential-of-Stroke-Coding-and-Documentation.pdf

Coding “Possible” Diagnoses: Inpatient vs Outpatient Rules Explained

Wed, 31 Dec 2025 20:36:54 GMT

Coding “Possible” Diagnoses: Inpatient vs Outpatient Rules Explained

Terms such as possible, probable, suspected, and likely frequently appear in patient records and are a top source of coding errors. Understanding when these diagnoses may be coded and when a query is required is critical for both inpatient and outpatient facility coding.

Inpatient Coding Rules for Possible, Probable, and Suspected Diagnoses

For inpatient admissions:

A diagnosis documented as possible, probable, suspected, or likely may be coded only if it remains documented as such at the time of discharge.
“At the time of discharge” refers to the provider’s final assessment, typically reflected in the discharge summary (DS) or final discharge note.
If the DS does not mention the possible diagnosis, even if a final progress note lists it, it cannot be coded.
Coders may query if documentation is ambiguous between progress notes and DS.

Key principle : The discharge summary represents the provider’s final assessment and controls coding.

Outpatient and Observation Coding Rules for Uncertain Diagnoses

For outpatient or observation encounters:

Uncertain diagnoses may never be coded.
Only confirmed diagnoses documented by the provider during the encounter can be assigned an ICD-10-CM code.
Documentation of “possible,” “suspected,” or “probable” diagnoses should instead be coded as signs, symptoms, or abnormal findings (e.g., cough, fever, abdominal pain).

Bottom line: OP coding is stricter than IP and possible or suspected diagnoses are never coded, even if persistent at the end of the encounter.

When Coders Should Initiate a Query

A query should be initiated when:

Early documentation lists a possible diagnosis
Later documentation is conflicting or unclear
The discharge summary omits the diagnosis entirely

Note: Coders should not assume persistence of a diagnosis across the stay.

Coding Example: Conflicting Documentation at Discharge

IP Example:

Day 1 Progress Note (IP): "Possible pneumonia: chest X-ray pending.”
Final Progress Note (IP): “Pneumonia still possible, patient improving.”
Discharge Summary (IP): “Patient tolerated diet and activity. No acute issues documented.”

Correct Coding (IP):

Do NOT code pneumonia
Code the signs/symptoms (e.g., cough, fever)
Consider a query if clarification is warranted

OP Example:

Same scenario in an observation or outpatient visit
Correct Coding (OP): Never code pneumonia; only code presenting symptoms

Key Coding Takeaways for Uncertain Diagnoses

“At the time of discharge” = provider’s final assessment, typically the DS
Uncertain diagnoses not referenced at discharge cannot be coded
Conflicting documentation requires a query, not assumption
Proper application is a top inpatient audit focus

Tracy Blevins, MSHIM, RHIA

Senior Consultant, Audit at UASI

Works Cited:

Centers for Medicare & Medicaid Services. ICD-10-CM Official Guidelines for Coding and Reporting, FY 2025–2026. Section II.H – Uncertain Diagnoses. Available here: https://www.cms.gov/files/document/fy-2025-icd-10-cm-coding-guidelines.pdf

American Hospital Association & Verhovshek, J. Coding uncertain diagnoses. AAPC Knowledge Center (AHA Coding Clinic for ICD-10-CM/PCS, First Quarter 2018: “Uncertain Diagnosis – Concern For”). Available here: https://www.aapc.com/blog/34764-coding-uncertain-diagnoses/

ICD-10-CM Contusion Code Updates for FY 2026

Wed, 17 Dec 2025 14:34:45 GMT

ICD-10-CM Contusion Code Updates for FY 2026

Overview of FY 2026 Contusion Code Changes

The FY 2026 ICD-10-CM update, effective October 1, 2025, introduced new diagnosis codes for contusions of the midsection.

Contusions are commonly seen in urgent care centers, primary care practices, orthopedic offices, and emergency departments. The existing abdominal wall contusion codes (S30.1XXA-S30.1XXS) will be deleted and replaced by a range of codes offering more specificity.

New ICD-10-CM Codes for Abdominal Wall, Groin, and Flank Contusions

Abdominal wall, groin, and flank:  New parent codes have been introduced:
S30.11:  Contusion of abdominal wall
S30.12:  Contusion of groin
S30.13:  Contusion of flank

General ICD-10-CM Coding Guidelines for Contusions

Specificity:  Always code to the highest level of specificity. When the location of the contusion is known, use a more specific code than a general one.
Encounter type:  The seventh character of the code indicates the encounter type.
A:  Initial encounter
D:  Subsequent encounter
S:  Sequela
Multiple injuries:  If the patient has multiple contusions, code each one individually.
Underlying injury:  If the contusion is related to another injury, such as a fracture, code the more severe injury first.
Provider guidance:  Consult with the medical provider for the most accurate diagnosis and coding.

Why the FY 2026 Contusion Updates Matter

Increased specificity:  The new codes allow for more precise documentation of the injury's location.
Updated documentation:  Providers must update their documentation and systems to use these new codes to avoid claim denials.
More specific details:  The updates reflect an ongoing effort in ICD-10 to increase granularity across many conditions.

Injury Coding Rules Relevant to Contusions

When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. Codes from category T07, Unspecified multiple injuries should not be assigned in the inpatient setting unless information for a more specific code is not available. Traumatic injury codes (S00- T14.9) are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds. The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.

*Coding Considerations for Superficial Injuries: Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site.

Theresa Bond, CPC, CPMA

Medical Audit Consultant at UASI

Theresa is a ProFee Coder and Provider Auditor with more than 13 years of coding experience and 7 years focused on auditing and education. She specializes in pro-fee E/M, inpatient surgery coding, and provider documentation audits, with extensive experience supporting compliance, reducing denials, and educating both coders and providers. Theresa is a member of the American Academy of Professional Coders (AAPC).

Works Cited

Centers for Medicare & Medicaid Services. (2025). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026.

Available at https://www.cms.gov/files/document/fy-2026-icd-10-cm-coding-guidelines.pdf

American Academy of Professional Coders. (2025). CMS releases FY 2026 ICD-10-CM update.
Available at https://www.aapc.com/blog/92808-cms-releases-fy-2026-icd-10-cm-update/

Secondary Diagnosis Reporting in Inpatient Coding: Why the Details Matter

Wed, 17 Dec 2025 14:10:11 GMT

Secondary Diagnosis Reporting in Inpatient Coding: Why the Details Matter

Why Accurate Secondary Diagnosis Reporting Is Critical

Understanding when a condition meets coding guidelines for reporting as a secondary diagnosis is critical to ensuring that coded data accurately represents patient care. Precise code assignment influences quality reporting, performance metrics, and reimbursement. When secondary conditions are incorrectly coded—whether through overcoding or underreporting—it can lead to significant consequences such as compliance risks, audit exposure, inaccurate quality scores, and misrepresentation of both patient acuity and organizational performance.

Applying the Official Definition of “Other (Additional) Diagnoses”

A secondary diagnosis is reportable when it affects patient care by requiring one or more of the following:

Clinical evaluation: The provider assesses or monitors the condition (e.g., monitoring symptoms, evaluating serial lab tests, imaging, or specialist consultation).
Therapeutic treatment: The condition receives active treatment (e.g., medication management, wound care, transfusion).
Diagnostic procedures: Testing is performed to evaluate the condition.
Extended length of stay or Increased nursing care: The condition contributes to increased complexity or length of stay.

Identifying Valid Secondary Diagnoses Through Clinical Indicators

A diagnosis listed in the past medical history or mentioned once in the record should not automatically be reported. Coders must review the chart for evidence that the condition was evaluated, treated, or influenced care.

Examples:

Reportable: Hypertension requiring daily medication during admission for pneumonia is reportable as a secondary diagnosis.
Not reportable: Glaucoma noted solely in past medical history, without current treatment or clinical impact during an admission for cholecystitis/cholecystectomy, does not meet criteria for reporting as a secondary diagnosis.

Documentation Requirements for Secondary Diagnosis Assignment & Common Pitfalls

If documentation is unclear, inconsistent, or conflicts with clinical findings, query the provider.

Documentation of pancytopenia, platelets within normal range.

Pitfalls:

Coding incidental findings that did not impact care.
Assigning chronic conditions without evidence of evaluation or management.
Reporting resolved problems from prior admissions not addressed in current encounter.

Annette Brehl, RHIA, CCS, CCS-P

Senior Consultant, Quality at UASI

Annette Brehl is an Inpatient Coding Audi tor and Educator at UASI, known for elevating coding quality through in-depth documentation analysis, a strong command of regulatory and coding guidelines, and targeted education. She shares coding tips informed by audit findings that helpcoders strengthen their accuracy, consistency, and confidence.

Works Cited

The 2026 CMS Five Star Rating Rule: How the CMS Five Star Rating Can Create Long-Term Risk for Hospitals

Mon, 15 Dec 2025 14:22:32 GMT

The 2026 CMS Five Star Rating Rule: How the CMS Five Star Rating Can Create Long-Term Risk for Hospitals

Beginning in 2026, updates to the CMS Five Star Rating methodology introduce a far more punitive and long-term consequence for hospitals with lower safety performance. Any hospital that falls into the bottom quartile for safety will be blocked from achieving a 5-Star rating and may be automatically downgraded to 1-Star in future cycles—even if clinical quality improves later.

This shift transforms what once felt like an annual performance challenge into a multi-year financial and reputational constraint.

Several components of the CMS Five Star Rating are influenced by safety-related measures, including patient safety indicators , which play a role in how hospitals are evaluated across reporting periods.

How the CMS Five Star Rating Methodology Changes Under the 2026 Rule

Under the revised CMS Five Star Rating model, safety performance becomes a gating mechanism for a hospital’s overall rating. Falling into the bottom quartile no longer affects only the current reporting year. Instead, the designation limits upward movement in subsequent cycles, making it more difficult for hospitals to recover once they fall behind.

Even with strong clinical care, the star rating may not immediately reflect improvements due to historical weighting and lookback periods used in CMS calculations. This lag increases the risk that lower ratings will persist long after care delivery has improved.

How Documentation Issues Affect CMS Medicare Star Ratings

Safety quartile placement under the CMS Five Star Rating program is influenced not only by clinical outcomes but also by how accurate events are captured in documentation. Inconsistencies in cataloging clinical data, present-on-admission (POA) designations, or coding detail can inadvertently elevate safety event counts.

Even small inaccuracies may create a misleading representation of patient safety performance—pushing hospitals into the bottom quartile and triggering the long-term downgrade risk outlined in the 2026 rule. Proactive alignment between documentation and clinical activity is now one of the most controllable ways to avoid unintended rating impact for your Stars rating.

The Long-Term Implications of Low Hospital Star

Ratings CMS Reports

A 1-Star designation affects far more than year-end quality reporting. Because the revised CMS Five Star Rating model limits upward mobility over multiple cycles, the consequences can compound year after year.

Hospitals may experience:

Contracting & Revenue Limitations: Reduced leverage in payer negotiations and limited inclusion in preferred networks.
Volume & Market Share Declines: Employers, consumers, and digital navigation tools increasingly direct patients toward higher-rated hospitals.
Margin Pressure: A weaker payer mix, higher underpayments, and diminished leverage in billing disputes.
Growth & Valuation Challenges: Lower ratings influence partnerships, employer agreements, affiliations, and investment confidence.
Workforce Strain: Physicians and APPs often avoid joining hospitals with persistent 1-Star ratings, increasing recruitment and retention costs.

Financial impact may occur immediately, but recovery within CMS reporting is gradual—resulting in long-term consequences even after performance improves.

How the Star Rating Program Creates Long-Term Performance Challenges

Once a hospital falls into the bottom safety quartile, the pathway back to a higher standing within the star rating program becomes slow and difficult. Because CMS blends historical data with current performance, real-time improvements rarely translate into immediate rating changes. This lag can extend reputational and financial challenges for years beyond the initial downgrade—long after underlying issues have been resolved.

To prepare for the 2026 rule, hospitals should complete a focused assessment to understand where safety event inflation or documentation inconsistencies may be influencing their performance within the star rating program. An effective readiness assessment should:

Quantify potential downgrade exposure in financial terms
Pinpoint documentation patterns that may be affecting safety event reporting
Identify opportunities to reduce downstream financial risk
Establish a roadmap aligned to the 2026 CMS rating methodology

Taking these steps now can help hospitals strengthen their safety profile and prevent prolonged rating challenges under the evolving star rating program framework.

The Bottom Line

The 2026 CMS Five Star Rating rule fundamentally changes how long hospitals may feel the effects of a single year of poor performance. Even hospitals with high clinical quality may be at risk if documentation doesn’t accurately reflect patient care.

Now is the time to reinforce documentation accuracy, verify how safety events are captured, and address any preventable factors that could affect safety quartile placement—before a downgrade shapes financial and operational outcomes for years to come.

Linda Wiseman, BSN, RN, CCDS

Director, CDI Services at UASI

References & Additional CMS Resources

Centers for Medicare & Medicaid Services. (2024). Technical notes for the overall hospital quality star rating . Available at :
https://www.cms.gov/files/document/overall-star-rating-methodology.pdf

Centers for Medicare & Medicaid Services. (2024). Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and policy changes . Federal Register. Available at:
https://www.federalregister.gov

for Medicare & Medicaid Services. (2024). Present on admission (POA) indicator reporting . Available at:
https://www.cms.gov/medicare/medicare-fee-service-payment/hospitalacqcond/poa

Symptoms of PRES: Diagnosis, Treatment, and ICD-10-CM Coding Guidance

Tue, 09 Dec 2025 14:35:11 GMT

Symptoms of PRES: Diagnosis, Treatment, and ICD-10-CM Coding Guidance

Introduction to PRES Symptoms, Causes, and Coding

Posterior Reversible Encephalopathy Syndrome (PRES), also known in clinical literature as reversible posterior leukoencephalopathy syndrome, is a neurologic condition characterized by acute changes in mental status, seizures, headaches, and visual disturbances. Because the symptoms of PRES can overlap with other encephalopathic presentations, accurate documentation is essential for correct ICD-10-CM coding, DRG assignment, severity capture, and CDI review.

What Is PRES? Understanding the Medical Term and Clinical Features

PRES is a clinical radiographic syndrome defined by a constellation of neurologic symptoms and characteristic imaging findings. Alternate terminology includes:

Reversible posterior leukoencephalopathy syndrome (RPLS)
Reversible posterior cerebral edema syndrome
Hyperperfusion encephalopathy
Brain capillary leak syndrome

Common clinical presentations include:

Headache
Seizures
Altered mental status or confusion
Visual disturbances (blurred vision, cortical blindness, visual field loss)

Clinical settings commonly associated with PRES include hypertensive crisis, cytotoxic immunosuppressive therapy, pre-eclampsia/eclampsia , and other conditions that cause endothelial injury.

Imaging Findings That Support a Diagnosis of PRES

Neuroimaging, particularly MRI, typically shows:

Vasogenic edema
Predominant involvement of posterior cerebral regions
Symmetric white matter changes

These imaging features are foundational in differentiating PRES from other encephalopathies.

Treatment of PRES and Key Management Principles

The treatment of PRES focuses on addressing the underlying cause and preventing further neurologic injury. Management strategies include:

Tight blood pressure control
Discontinuation of offending agents (especially cytotoxic medications)
Seizure management
Obstetric protocols when PRES occurs during pregnancy (treated as pre-eclampsia or eclampsia)

Most patients recover within two weeks; however, some may experience persistent neurologic deficits or, in severe cases, complications such as intracranial hemorrhage or cerebral infarction.

ICD-10-CM Coding for PRES (I67.83) and CDI Considerations

The ICD-10-CM code for PRES is I67.83.

Key coding and CDI notes:

PRES is classified as an MCC when assigned as a secondary diagnosis.
When PRES is the principal diagnosis, it groups to MS-DRG 070, 071, or 072 (Other cerebrovascular disorders).
Cerebral edema is not coded separately, as it is inherent to PRES.
PRES is a recognized risk-adjusting condition demonstrating severity of illness.
Documentation must clearly link PRES to the underlying cause when clinically supported.
Documentation of “encephalopathy” alone does not support coding PRES; a CDI query is indicated if the diagnosis is unclear or inconsistently documented.

Secondary Diagnoses That Impact DRG and Severity Capture

When reviewing documentation, CDI specialists should assess for commonly associated secondary diagnoses, including:

Acidosis
Acute renal failure
Coma
Cerebral infarction or stroke
ESRD
Secondary hyperparathyroidism

These conditions may significantly impact DRG assignment and severity reporting.

Query Opportunities for PRES Documentation

A CDI query may be appropriate when:

“Encephalopathy” is documented without clarification of the type
Imaging findings are consistent with PRES but the provider does not document the diagnosis
The underlying cause (e.g., hypertensive crisis, cytotoxic drug use, pre-eclampsia) is not explicitly linked to PRES
Conflicting terminology appears in the record

Strengthen Your CDI Accuracy With UASI

Looking for more guidance on complex neurologic diagnoses, ICD-10-CM documentation requirements, and DRG-impacting conditions? Explore more CDI best practices and real-world scenarios in UASI’s educational library.

Continue Learning: Visit UASI's CDI Tips and Scenarios

Alyce Reavis, RN,MSN,CCDS,CCS

Senior CDI Educator, Consulting Services at UASI

Works Cited

Centers for Medicare & Medicaid Services. (2025). FY 2026 Official Guidelines for Coding and Reporting.
Available at https://www.cms.gov

Centers for Medicare & Medicaid Services. (2025). IPPS Final Rule for Fiscal Year 2026.
Available at https://www.cms.gov

Neill, T. (2025). Posterior reversible encephalopathy syndrome. UpToDate.
Available at https://www.uptodate.com/contents/posterior-reversible-encephalopathy-syndrome

Welcome Lena Wilson

Tue, 02 Dec 2025 14:17:17 GMT

UASI Welcomes Lena Wilson as Client Success Manager

UASI proudly welcomes Lena Wilson, MHI, RHIA, CCS, CCDS, in her new role as Client Success Manager. In this role, Wilson will lead strategic client engagement, onboarding, and long-term success initiatives across UASI’s CDI, denials management, and revenue integrity service lines.

With 20 years of CDI and coding experience, Wilson brings experience in building, scaling, and optimizing CDI programs across complex health systems. Her background spans academic, community, pediatric, and critical access care environments, including oversight for multi-facility CDI operations.

“Lena’s combination of clinical documentation leadership, operational strategy, and unwavering focus on measurable outcomes makes her an outstanding addition to UASI,” said Autumn Reiter, Chief Strategy and Solutions Officer “Her history of driving quality, compliance, and financial impact across large, diverse hospital networks directly aligns with our mission to deliver results and lasting value for our clients.”

Prior to joining UASI, Wilson served as Manager of Clinical Documentation Integrity at Indiana University Health, where she led a systemwide CDI program supporting up to 16 facilities and managed a team of more than 20 CDI professionals. She guided major CDI technology transitions, including MModal Collaborate, Solventum (3M 360), and Iodine, and built education and quality programs to sustain performance during change.

Wilson is widely recognized for her commitment to advancing CDI practice at the national level. She has served on the ACDIS Board of Directors (2010–2012 and 2021–2025) and ACDIS Leadership Council (2021-2025). She has also presented on CDI strategy and outcomes at regional, state, and national forums.

“I’m excited to join UASI and partner with organizations that are committed to clinical excellence, compliant reimbursement, and stronger documentation practices,” said Lena Wilson. “UASI has built a reputation for blending expertise with true client partnership, and I look forward to helping our clients achieve meaningful, sustainable results.”

CDI Tip: ICANS Grading and Accurate Documentation

Mon, 01 Dec 2025 20:13:25 GMT

CDI Tip: ICANS Grading and Accurate Documentation

Understanding ICANS in CAR T-Cell Therapy Neurotoxicity

Immune effector cell–associated neurotoxicity (ICANS) is a common and potentially severe complication of CAR T cell therapy neurotoxicity and other immune effector cell therapies. It occurs in 20–60% of CAR T-cell recipients and may range from mild confusion to life-threatening cerebral edema.

For CDI specialists , accurate ICANS grading using standardized criteria is essential for correct ICD-10-CM assignment, severity capture, risk adjustment, and quality reporting.

Pathophysiology and Risk Factors

ICANS is believed to result from cytokine-mediated inflammation , immune activation, and changes in blood–brain barrier permeability. Documentation should reflect contributing factors, including:

Cytokine Release Syndrome (CRS)
Preexisting neurological dysfunction
Tumor burden
Elevated LDH or ferritin
High CAR T-cell dose
Younger patient age
Intensive lymphodepleting therapy

These factors increase susceptibility to neurotoxicity associated with CD19 targeted CAR T cell therapies .

Clinical Indicators for CDI Review

Ensure that provider documentation includes relevant indicators of neurotoxicity:

Confusion, somnolence, slowed cognition
Seizures (clinical or EEG-confirmed)
Cranial nerve palsies, motor weakness
Elevated intracranial pressure (ICP)
Cerebral edema or posturing

These findings support accurate ICANS grading and ICD-10 coding.

The ICANS Grading System (ICE Score)

ICANS is evaluated using the ICE score , which assesses orientation, naming, commands, handwriting ability, consciousness level, motor deficits, seizures, and signs of increased ICP.

Documentation should clearly reflect the ICANS grading ICE score , which directly affects code assignment and severity classification.

Treatment Considerations Supporting Documentation

Common therapies for ICANS include:

Supportive care
Antiseizure agents or benzodiazepines
Corticosteroids (e.g., dexamethasone)
ICU care for severe neurotoxicity
Tocilizumab only if CRS is present

Treatment details often help CDI professionals validate ICANS severity and grade.

ICD-10-CM Codes for ICANS

Immune effector cell–associated neurotoxicity syndrome, G92.0

ICANS, grade 1: ICD-10 Code: G92.01
ICANS, grade 2: ICD-10 Code: G92.02
ICANS, grade 3: ICD-10 Code: G92.03
CC/MCC: CC
ICANS, grade 4: ICD-10 Code: G92.04
CC/MCC: CC
ICANS, grade 5: ICD-10 Code: G92.05
CC/MCC: CC
ICANS, unspecified: ICD-10 Code: G92.00'

Coding Note: Always report the underlying condition, immunotherapy used, and related complications (e.g., CRS) in addition to the ICANS diagnosis.

Explore More CDI Insights

For additional CDI Tips, regulatory updates, and documentation guidance: UASI's CDI Tips and Scenarios

Alyce Reavis, RN,MSN,CCDS,CCS

Senior CDI Educator, Consulting Services at UASI

Works Cited

Centers for Medicare & Medicaid Services. Official Guidelines for Coding and Reporting. Available at https://www.cms.gov

Dietrich, J., & Frigault, M. J. Immune effector cell–associated neurotoxicity syndrome (ICANS) and other neurologic toxicities of CAR-T cell and related therapies. UpToDate, 2025. Available at https://www.uptodate.com/contents/immune-effector-cell-associated-neurotoxicity-syndrome-icans-and-other-neurologic-toxicities-of-car-t-cell-and-related-therapies

Prescott, L., & Manz, J. ACDIS CDI Pocket Guide – Inpatient. Available at https://acdis.org/

CMS Regulations for 2026: Key Updates Healthcare Leaders Must Prepare For

Mon, 01 Dec 2025 15:45:59 GMT

CMS Regulations for 2026: What Healthcare Organizations Need to Know

CMS has released several major cms regulations impacting Medicare, Medicaid, physician payment, Medicare Advantage, data privacy, and program administration for 2026. These updates — published in late November and early December — bring important changes for reimbursement, documentation, compliance, and mid-revenue cycle operations.

Healthcare leaders, revenue integrity teams, and CDI/coding professionals should begin preparing immediately. For deeper guidance, explore our mid-revenue cycle insights .

For organizations tracking CMS quality measures and PSI performance, our quality and PSI solutions page provides an overview of how these programs are operationally supported.

CY 2026 Physician Fee Schedule: Payment, Documentation & Quality Reporting Changes

The CY 2026 Physician Fee Schedule introduces several cms rule changes that will influence reimbursement structures, documentation practices, and cms quality reporting expectations for hospitals and physician groups. CMS is updating conversion factors, refining E/M guidelines, and adjusting Medicare payment policies across a wide range of specialties. The 2026 rule places stronger emphasis on accurate documentation and adherence to evolving cms documentation requirements, particularly in areas that impact compliance and improper payment prevention. Because these updates tie directly to healthcare regulations and national value based care priorities, leaders should closely monitor how RVU adjustments, telehealth provisions, and supervision requirements may affect operational planning and financial performance in the year ahead.

Privacy Act of 1974 Matching Program

CMS has renewed and expanded its Matching Program under the Privacy Act of 1974, enabling wider data comparisons to verify eligibility for federal and state health programs. The November 2025 update enhances identity and income verification processes, supporting more accurate administration of subsidies and coverage determinations. These cms updates are designed to reduce improper payments and strengthen national regulatory compliance healthcare initiatives. As part of the expanded matching protocol, CMS will compare Exchange eligibility information with federal and state databases to confirm citizenship status, household income, and other eligibility factors. These changes also reinforce the importance of accurate documentation and internal data governance, as organizations must ensure alignment with CMS’s verification standards and broader healthcare regulations.

CMS Quarterly Issuances (Q4 2025): What’s New

CMS’s Q4 2025 Quarterly Issuances outline recent cms updates across Medicare and Medicaid, including operational instructions, manual revisions, and new cms quality reporting guidance. These quarterly publications help organizations stay current with evolving healthcare regulations and operational requirements that affect reimbursement, documentation workflows, and participation in programs tied to value based care incentives. The Q4 release includes updates to coverage policies, national coverage determinations, and technical rules that may impact risk adjustment activities, quality performance, and compliance planning throughout 2026. Staying ahead of these changes allows teams to prepare proactively, particularly those involved in coding, CDI, and financial oversight.

What These CMS Regulations Mean for Healthcare Organizations

The 2026 CMS regulatory updates carry significant financial consequences for hospitals, health systems, and physician groups. Changes to reimbursement formulas, documentation standards, and quality reporting requirements will directly influence both fee-for-service payments and value-based care incentives . Under the CY 2026 Physician Fee Schedule, even small adjustments to RVUs, conversion factors, or quality measures can translate into substantial revenue shifts across high-volume service lines.

For organizations participating in risk-based arrangements , updates to documentation requirements and quality metrics will impact RAF-driven reimbursement , STAR ratings performance, and operational budgets tied to quality improvement initiatives. CMS’s new quarterly issuance cycle also means that payment methodologies, coverage decisions, and compliance expectations may shift more frequently—requiring tighter coordination between coding, CDI, quality, and finance teams.

As margins remain thin and labor costs remain high across the industry, timely alignment with these CMS regulatory changes will be essential to avoid revenue leakage, safeguard incentive payments, and maintain financial stability heading into FY 2026 and beyond.

Strong mid-revenue cycle processes will be critical for successful adaptation. See how UASI supports hospitals and physician groups nationwide.

Works Cited

Centers for Medicare & Medicaid Services. Medicare and Medicaid Programs; CY 2026 Payment Policies Under the Physician Fee Schedule and Other Revisions. Federal Register, 28 Nov. 2025. Available at: https://www.federalregister.gov/documents/2025/11/28/2025-21458/medicare-and-medicaid-programs-cy-2026-payment-policies-under-the-physician-fee-schedule-and-other

Centers for Medicare & Medicaid Services. Medicare Program; Contract Year 2027 Policy and Technical Changes to the Medicare Advantage Program. Federal Register, 28 Nov. 2025. Available at: https://www.federalregister.gov/documents/2025/11/28/2025-21456/medicare-program-contract-year-2027-policy-and-technical-changes-to-the-medicare-advantage-program

Centers for Medicare & Medicaid Services. Privacy Act of 1974; Matching Program—Determining Eligibility for Enrollment in Applicable State Health Subsidy Programs Under the PPACA. Federal Register, 18 Nov. 2025. Available at: https://www.federalregister.gov/documents/2025/11/18/2025-20058/privacy-act-of-1974-matching-program

Centers for Medicare & Medicaid Services. Medicare and Medicaid Programs; Quarterly Listing of Program Issuances: July Through September 2025. Federal Register, 1 Dec. 2025. Available at: https://www.federalregister.gov/documents/2025/12/01/2025-21622/medicare-and-medicaid-programs-quarterly-listing-of-program-issuances-july-through-september-2025

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Medicare Costs Are Rising in 2026

Wed, 19 Nov 2025 14:22:25 GMT

Medicare Costs in 2026: Key CMS Announcements and What They Mean

How CMS Announcements Influence Medicare Costs

Over the last 24 hours, a wave of federal healthcare announcements has been released—many with meaningful implications for hospitals, laboratories, and Medicare beneficiaries. From rising premiums to accreditation renewals and administrative rule-making, the updates collectively signal a 2026 landscape marked by higher patient cost-sharing and continued regulatory complexity for providers. Below is a concise breakdown of each notice and its financial impact across the industry.

As CMS cost and quality measures continue to evolve, ou r quality and PSI solutions page outlines how these performance programs are supported across healthcare organizations.

Privacy Act Matching Program (2025-20058)

CMS renewed a computer-matching program used to compare federal and state data for the purpose of validating eligibility, detecting inaccurate information, and reducing improper payments in benefit programs. These matching agreements are a major enforcement tool in federal oversight efforts.

Impact on consumers: While there is no direct cost implication, beneficiaries may experience tighter verification processes or more frequent documentation requests.

Impact on hospitals: Providers could see increased administrative follow-up for eligibility confirmations and potentially more audit-related interactions if discrepancies are flagged.

Re-Approval of The Joint Commission (2025-20329)

CMS officially re-approved The Joint Commission (TJC) to serve as an accrediting authority for hospitals participating in Medicare. Accreditation is an essential requirement for hospitals to receive Medicare reimbursement, so this renewal assures continuity for thousands of facilities nationwide.

Impact on consumers: Maintains consistent quality and safety oversight across accredited hospitals, ensuring reliable access to compliant facilities.

Impact on hospitals: Eliminates the risk of program disruption and helps hospitals continue receiving Medicare payments without needing to modify their accreditation pathway.

Re-Approval of COLA Under CLIA (2025-20328)

CMS renewed the authority of the Commission on Office Laboratory Accreditation (COLA) to accredit laboratories under the Clinical Laboratory Improvement Amendments (CLIA). This ensures laboratories accredited by COLA can continue to operate and bill Medicare for diagnostic testing.

Impact on consumers: Helps ensure stable access to high-quality lab testing and prevents service interruptions.

Impact on hospitals and labs: Accreditation continuity reduces operational uncertainty and supports consistent reimbursement for diagnostic services.

Medicare Part B Premiums and Deductible for 2026 (2025-20251)

CMS announced that Medicare Part B premiums and deductibles will rise significantly in 2026, reflecting updated actuarial projections, increased healthcare spending, and program cost trends. The standard monthly premium will increase to approximately $202.90, and the annual deductible will increase to $283.

Impact on consumers: These increases represent a substantial rise in annual out-of-pocket costs, especially for beneficiaries on fixed incomes. Higher-income beneficiaries paying IRMAA will see proportionally larger increases.

Impact on hospitals: As patient cost-sharing increases, providers often see reduced utilization for non-urgent services and a rise in patient balances that are difficult to collect.

Part A Premiums for Uninsured or Limited-Work Beneficiaries (2025-20250)

CMS also released the 2026 Part A premium amounts for individuals who do not qualify for premium-free Part A due to insufficient work credits. Premiums will increase to $311 for individuals with 30–39 quarters of work and $565 for those with fewer than 30 quarters.

Impact on consumers: This is a significant financial burden for the small group that must purchase Part A coverage outright, potentially affecting their ability to maintain enrollment.

Impact on hospitals: Providers may see delayed care or lapses in coverage for financially vulnerable beneficiaries who struggle with premium increases.

Inpatient Hospital Deductible and Coinsurance for 2026 (2025-20249)

The Medicare Part A inpatient hospital deductible will increase to $1,736, and associated coinsurance amounts for extended hospital and SNF stays will also rise. These increases reflect annual inflationary adjustments in the Medicare program.

Impact on consumers: Higher deductibles and coinsurance mean more out-of-pocket responsibility during hospitalizations and post-acute care.

Impact on hospitals: Increased patient financial responsibility often results in higher patient-balance collection challenges and heightened bad-debt exposure, particularly for long-stay patients.

What Stakeholders Should Do Now

As these announcements signal increased patient cost-sharing and renewed regulatory expectations, all healthcare stakeholders should begin preparing accordingly. Beneficiaries should review their Medicare plans, consider supplemental coverage, and budget for higher 2026 expenses. Hospitals and health systems need to anticipate rising patient balances, analyze potential impacts on service utilization, and prepare for additional administrative obligations tied to reporting and coding changes. Payers should update benefit designs and financial forecasts, while compliance teams remain alert to forthcoming CMS timelines and requirements. Together, these proactive steps will help organizations navigate a 2026 environment shaped by growing costs and heightened regulatory oversight.

Are you confident your coding team is ready for the 2026 updates? UASI can help you stay accurate, compliant, and ahead of regulatory changes. Contact UASI to strengthen your coding operations.

To view all announcements please visit our live healthcare policy feed.

Explore how Medicare costs and risk-adjustment strategies affect provider profitability.

The Financial Power of Quality Metrics and RAF Scores in Today’s Healthcare Landscape

Mon, 17 Nov 2025 15:43:28 GMT

The Financial Power of Quality Metrics and RAF Scores in Today’s Healthcare Landscape

The New Financial Equation in Healthcare

In today’s healthcare environment, risk and quality are directly tied to reimbursement.

The Centers for Medicare & Medicaid Services (CMS) has redefined how hospitals and physician groups are paid. Financial performance now depends on how effectively organizations document and demonstrate patient risk, quality outcomes, and safety, rather than simply the volume of services provided.

Metrics such as CMS Stars, Patient Safety Indicators (PSIs), and Hierarchical Condition Categories (HCCs) are no longer operational details. They are strategic financial drivers that influence competitiveness, reimbursement, and reputation.

Hospitals that master this alignment outperform their peers in both revenue growth and quality rankings. Those that do not are leaving significant risk-adjusted reimbursement on the table.

For more on how quality and PSI programs are supported, see our PSI and Quality Solutions overview.

How CMS Stars and Quality Metrics Connect to RAF Scores

The CMS Stars program is designed to reward high-quality, risk-adjusted performance.

Star ratings incorporate measures such as mortality, readmissions, and complications. Each is adjusted by Risk Adjustment Factors (RAFs) to account for patient complexity.

In practice, this means that when patient risk is not fully documented, hospitals appear to have healthier populations than they actually do. The result is artificially higher mortality or PSI rates and lower Star ratings.

Lower ratings reduce CMS incentive payments and marketplace visibility, while incomplete RAFs reduce per-member payments in risk-based contracts.

Each RAF point reflects a patient's true clinical complexity. Incomplete documentation suppresses those scores, which in turn suppresses both quality outcomes and financial performance.

Accurate RAF capture ensures that organizations are evaluated on an even playing field and reimbursed for the actual cost of care.

PSIs, HCCs, and the Risk-Quality-Revenue Connection

Patient Safety Indicators (PSIs) measure preventable harm. Hierarchical Condition Categories (HCCs) capture chronic and complex conditions that drive expected costs. Together, they create a risk and quality profile that determines financial performance.

When HCCs are underreported, patient risk is understated, which makes PSI and mortality results appear worse. This directly affects rankings, public perception, and revenue under CMS value-based programs.

Integrating Clinical Documentation Integrity (CDI), Quality, and Risk Adjustment functions allows organizations to build a complete picture of patient acuity. This unified approach strengthens documentation accuracy, improves publicly reported quality metrics, and supports compliance. Hospitals that align these efforts consistently achieve stronger outcomes across CMS Stars, U.S. News & World Report rankings, and commercial payer benchmarks.

Financial Reality: A Realistic ROI Model for RAF Optimization

The following model shows a realistic, blended return:

A 10% improvement in RAF accuracy yields a 4% blended revenue lift, or approximately $4 million in additional reimbursement. This gain comes entirely from better documentation and coding precision, not from increasing patient volume.

For most systems, that 4% translates into several million dollars in recaptured revenue annually, while also improving quality scores and compliance standing.

RAF Vue: Turning Documentation Accuracy into Financial Performance

RAF Vue by UASI is a SaaS solution designed for organizations that want to improve both reimbursement accuracy and quality performance.

Through advanced analytics, automated HCC identification, and real-time tracking, RAF Vue helps hospitals and physician groups:

Identify and close documentation gaps before submission
Monitor RAF trends and revenue impact across inpatient and outpatient settings
Quantify the financial effect of improved HCC capture
Unify CDI and Quality teams around shared objectives

By transforming risk documentation into measurable financial intelligence, RAF Vue enables organizations to realize the full value of risk-adjusted care.

Conclusion

CMS Stars, PSIs, HCCs, and RAFs are no longer technical metrics. They represent a new financial language that defines how healthcare organizations compete. Accurate risk capture improves quality ratings, strengthens compliance, and drives higher reimbursement. RAF Vue empowers hospitals and physician groups to achieve this alignment, unlocking both financial and clinical ROI.

Leah Jeffries, RHIT, CDIP, CCS, CCS-P

Managing Consultant, Strategy at UASI

Type 2 Diabetes in Remission — Understanding the New E11.A Code for FY 2026

Wed, 05 Nov 2025 15:57:35 GMT

Type 2 Diabetes in Remission — Understanding the New E11.A Code for FY 2026

The FY 2026 ICD-10-CM update, effective October 1, 2025, introduced a new diagnosis code — E11.A (Type 2 diabetes mellitus in remission).

This addition reflects growing recognition that some patients can achieve long-term remission of Type 2 diabetes, often after significant lifestyle changes or metabolic interventions such as bariatric surgery. For inpatient coders, this change allows for more precise data capture and accurate representation of a patient’s current clinical status.

What’s New

Prior to FY 2026, coders had limited options when providers documented phrases such as “Type 2 diabetes resolved” or “in remission.” These cases often led to inconsistent coding, since the only available choices were:

E11.xx — Active diabetes, or
No diabetes code at all

The addition of E11.A closes that gap. It recognizes patients who no longer meet the clinical criteria for active diabetes but remain at increased risk for recurrence. Type 2 DM in remission has been defined as achieving an HbA1C level of less than 6.5% for at least three months after cessation of all glucose lowering medication.

Documentation Requirements

To code E11.A, provider documentation must clearly state that the patient’s diabetes is “in remission.”

The term “controlled” or “well-controlled” is not enough — these still represent active disease.

Terms such as “history of T2DM” and “resolved T2DM” might be documented, but are not synonymous with T2DM in remission. When it is unclear, a provider should be queried

Here’s what coders should confirm in the health record:

Provider statement: The provider must explicitly state “Type 2 diabetes mellitus in remission.”
Treatment status: The patient should not be taking insulin or oral hypoglycemics.
Lab results: Normal glucose or HbA1c levels may support the remission status, but cannot be coded on their own without provider confirmation.
Duration of remission: While not required for coding, duration (e.g., “in remission for 2 years”) strengthens the clinical picture.

Coding Example

Documentation: “Patient with prior history of Type 2 diabetes, now maintains normal blood glucose and A1c after bariatric surgery. No current medications. Type 2 diabetes in remission.”

Code Assignment:

E11.A — Type 2 diabetes mellitus in remission

If the provider instead documents “controlled” or “diet-controlled diabetes,” continue to assign E11.9 — Type 2 diabetes mellitus without complications.

Common Pitfalls

Coding based on labs alone: Do not assign E11.A without a provider statement.
Using ‘history of diabetes’ only: A “history of” note without mention of remission does not qualify for E11.A.
Applying to Type 1 diabetes: The remission concept applies only to Type 2 diabetes at this time.
Omitting secondary risk codes: Consider Z86.39 (Personal history of other endocrine disorders) if the provider documents long-term follow-up without current disease.

Why This Matters

Accurate use of E11.A improves: Clinical communication: Providers and coders share a clear understanding of disease status.
Population health data: Public health agencies can track remission rates more accurately.
Risk adjustment and quality metrics: Prevents overcoding active disease, which can affect reporting, reimbursement, and care management metrics.
This small but meaningful change encourages better alignment between coding and real-world outcomes — reflecting advances in diabetes treatment and remission recognition.

References

FY 2026 ICD-10-CM Official Guidelines for Coding and Reporting (Effective 10/1/2025) Section 1.C.4.A.1.b
ICD-10-CM/PCS Coding Clinic, Fourth Qtr ICD-10 2025, Pages 6-7

Jessica Lutz, MBA, RHIA, CCS
AHIMA Micro-credential: Auditing: Inpatient Coding

Senior Consultant, Audit at UASI

Hyperbaric Oxygen Therapy (HBOT) Coding

Tue, 04 Nov 2025 18:52:30 GMT

Hyperbaric Oxygen Therapy (HBOT) Coding

HBOT is described as a treatment that utilizes pure oxygen in a high-pressure environment to aid in healing wounds/tissue that have been damaged by infection, poisoning or injuries. There must be an initial HBOT evaluation and/or consultation by a physician or nurse practitioner (NPP). Physician or Non-Physician Practitioner (NPP) order for date of service, if applicable. The documentation is very specific to the prescribing of HBOT as well as the treatment rendered.

Progress notes

HBO clinic/progress notes
Clinic/hospital/progress notes prior to starting HBO, if applicable
Support of the initial wound/condition etiology
Support of prior history of treatment for the condition/wound(s), if applicable

HBO Treatment plan

Atmospheric pressures
Rest/Air breaks
Frequency and number of dives
Blood glucose monitoring, if applicable
Wound assessments, if applicable
Evaluation of progress

HBO dive logs/treatment records

Documentation should include minutes completed during HBO treatment
Documentation should support when blood glucose measurements are taken and the results, if applicable

Wound treatment records or wound flow sheets supporting measurable signs of healing

Wound measurements, if applicable
Subjective findings regarding wound, if applicable

Diabetic wound(s) required documentation:

Wagner grade classification (must be Wagner grade III of higher) with diagnostic testing to support Wagner grade;
Patients have type 1 or type 2 diabetes and lower extremity wound due to diabetes.
Documentation supporting prior failed treatment using standard wound care.
Documentation supporting there were no measurable signs of healing for at least 30 consecutive days of treatment when using standard wound therapy.
Evaluation of wound(s) at least every 30 days during administration of HBO therapy that supports evidence of measurable signs of healing

Standard diabetic wound care therapy documentation required prior to starting HBO:

Assessment of patient's vascular status and correction of problems, if applicable
Support for optimization of nutritional status
Support of optimization of glucose control
Support of debridement of the devitalized tissue
Support of the wound care management that includes maintenance of a clean, moist bed of granulated tissue with appropriate moist dressing
Support of appropriate off-loading
Support of treatment to resolve infection

There must be separate documentation for an evaluation and management (E&M) service if provided on the same date of service as treatment.

The patient must be provided an Advance Beneficiary Notice of Noncoverage (ABN), if applicable.

Jane Keesler, AA, CCS

Senior Consultant at UASI

Works Cited:

Cleveland Clinic. (n.d.). Hyperbaric oxygen therapy.
Available at https://my.clevelandclinic.org/health/treatments/17811-hyperbaric-oxygen-therapy

Mayo Clinic. (n.d.). Hyperbaric oxygen therapy. Mayo Foundation for Medical Education and Research.
Available at https://www.mayoclinic.org/tests-procedures/hyperbaric-oxygen-therapy/about/pac-20394380

Centers for Medicare & Medicaid Services. (n.d.). National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29). Available at https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=12&ncdver=3&DocID=20.29

Gestational Diabetes

Mon, 03 Nov 2025 14:57:51 GMT

Gestational Diabetes

Gestational Diabetes Definition

Any pregnant person that shows abnormal glucose tolerance that was not present prior to the pregnancy. The American College of Obstetricians and Gynecologists (ACOG) define GDM as "a condition in which carbohydrate intolerance develops during pregnancy.” Preexisting (pregestational) diabetes refers to type 1 or 2 diabetes diagnosed before pregnancy.

Common Risk Factors:

GDM in a prior pregnancy
Family history of diabetes
Pre-pregnancy BMI ≥30 kg/m2, significant weight gain in early adulthood or between pregnancies, or excessive gestational weight gain during the first 18 to 24 weeks of pregnancy
Maternal age >/=35 years of age

Key Points for Accurate Documentation

Specify Diagnosis Clearly

Use the term “Gestational Diabetes Mellitus (GDM)” and indicate if it is diet-controlled (A1) or insulin/medication-controlled (A2).
Avoid vague terms like “borderline diabetes” or “glucose intolerance.”

Document Diagnostic Basis

Include OGTT results or note that diagnosis was based on ADA/ACOG criteria (e.g., abnormal 1-hour or 3-hour glucose tolerance test).

Capture Clinical Significance

Note any maternal or fetal complications (e.g., polyhydramnios, macrosomia, preeclampsia).
Document treatment plan: diet modification, insulin, oral agents, or glucose monitoring.

Differentiate from Pre-existing Diabetes

Confirm that hyperglycemia was first recognized during pregnancy. If diabetes existed before pregnancy, code as pre-gestational diabetes.

Postpartum Follow-up

Indicate if postpartum glucose testing or counseling for future diabetes risk was provided.

Why It Matters:

Precise documentation supports accurate ICD-10 coding (e.g., O24.41–O24.43), reflects severity of illness, and impacts quality metrics and reimbursement. AHRQ’s Maternity Care Measure Set includes post-partum glucose careening for gestational diabetes patients in Measure 10 – Post-Partum Follow-up and Care Coordination. This measure applies to all patients regardless of age, who gave birth during a 12-month period seen for post-partum care visit before or at 8-weeks of giving birth. There are no exceptions.

Alyce Reavis, RN,MSN,CCDS,CCS

Senior CDI Educator, Consulting Services at UASI

Works Cited:

ACOG / National Committee for Quality Assurance. (2012). Maternity Care Performance Measures Set.
Available at https://www.ahrq.gov/sites/default/files/wysiwyg/CHIPRA-BMI-Maternity-Care-Measures.pdf

American College of Obstetricians and Gynecologists. (2018). Gestational Diabetes Mellitus (Practice Bulletin No. 190).
Available at https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/02/gestational-diabetes-mellitus

Centers for Medicare & Medicaid Services. (2025). Official Guidelines for Coding and Reporting: ICD-10-CM, FY 2026.
Available at https://www.cms.gov/files/document/fy-2026-icd-10-cm-coding-guidelines.pdf

American Diabetes Association. (2025). Management of Diabetes in Pregnancy. Diabetes Care, 48(Supplement 1), S306–S320.
Available at https://diabetesjournals.org/care/article/48/Supplement_1/S306/157565/15-Management-of-Diabetes-in-Pregnancy-Standards

Durnwald, C. (2025). Gestational diabetes mellitus: Screening, diagnosis, and prevention. UpToDate.

Coding Chronic Inactive Gastritis

Thu, 30 Oct 2025 15:27:01 GMT

Coding Chronic Inactive Gastritis

Chronic inactive gastritis is often noted in an EGD result or path report.

It is important to still code this, even though it is “inactive” as it can still greatly affect the patient’s quality of life and can increase the risk of developing stomach cancer in the future. In some cases, untreated inactive gastritis can progress to active gastritis, which may require more aggressive treatment.

INACTIVE VS ACTIVE Gastritis

Inactive: chronic inflammation of stomach lining without tissue damage or injury

Active: chronic inflammation with presence of neutrophils in stomach lining, with ongoing tissue damage or injury (example: with infection or ulceration)

The neutrophils being there show the immune system is attempting to actively fight an issue.

ICD-10 Codes don’t differentiate between active & inactive gastritis:

K29.50 chronic gastritis without bleeding

K29.51 chronic gastritis with bleeding

Add code for infection, if that applies (example: B96.81 for Helicobacter pylori)

Other specified gastritis has specific codes (atrophic, superficial, alcoholic, etc. – see ICD-10 index)

What This Means in Practice

Code chronic gastritis, even if documented as inactive
Code to highest specificity according to ICD-10-CM index and tabular
Code any secondary conditions that further explain in detail the patient’s condition

Katie Brown, CCS

Senior Consultant, Audit at UASI

Works Cited

Singh, N. (2023, July 14). Chronic inactive gastritis: Causes, symptoms, diagnosis, and treatment. iCliniq.
Available at https://www.icliniq.com/articles/gastro-health/chronic-inactive-gastritis#:~:text=Chronic%20inactive%20gastritis%20is%20a%20type%20of%20gastritis%20marked%20by,vomiting%2C%20and%20loss%20of%20appetite .

CRISPR: Cell-based gene therapy for treatment of sickle cell disease

Tue, 28 Oct 2025 13:19:28 GMT

CRISPR: Cell-based Gene Therapy for Treatment of Sickle Cell Disease

Understanding CRISPR Gene Therapy for Sickle Cell Disease

The FDA has approved the first cell-based gene therapy for treatment of sickle cell disease in patients 12 and older.

CRISPR can be directed to cut DNA in targeted areas, enabling the ability to accurately edit DNA where it has been cut.

Think of your DNA as an instruction manual for how your body works. Sometimes, there’s a typo in the manual that causes problems, like sickle cell disease. CRISPR is like a pair of tiny scissors and a GPS system combined. It can find the exact spot of the typo in the DNA and either fix it, remove it or replace it with the correct instructions. In CASGEVY gene therapy, physicians use CRISPR to repair or change these faulty instructions so that cells can work properly again.

How Do We Capture This:

This treatment is used for patients with recurrent vaso-occlusive crises or with a history of vaso-occlusive events.

Select the correct administration route – central or peripheral vein:

Understanding How Section X Codes Are Reported in

ICD-10-PCS

Section X codes are standalone codes. They are not supplemental codes. Section X codes fully represent the specific procedure described in the code title, and do not require any additional codes from other sections of ICD-10-PCS. When section X contains a code title which describes a specific new technology procedure, only that X code is reported for the procedure. There is no need to report a broader, non-specific code in another section of ICD-10-PCS. The X code captures the administration so no additional code is needed.

Capturing ICD-10-PCS codes for new technologies is under-captured. To ensure your coders are capturing new technologies, check to see if your EHR has the capability to FLAG these new technologies with an alert.

Liz Burson, BS, CCS

Senior Consultant, Audit at UASI

Works Cited

Cobb, B. (2024, October 2). New technologies eligible for add-on payment in CMS IPPS FY 2025. Medical Management Plus, Inc.
Available at https://www.mmplusinc.com/kb-articles/new-technologies-eligible-for-add-on-payment-in-cms-ipps-fy-2025

U.S. Food & Drug Administration. (2023, December 8). FDA approves first gene therapies to treat patients with sickle cell disease [Press release]. Available at https://www.fda.gov/news-events/press-announcements/fda-approves-first-gene-therapies-treat-patients-sickle-cell-disease

U.S. Centers for Medicare & Medicaid Services. (2016). Using the ICD-10-PCS new technology section codes.
Available at https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-Section-X-New-Technology-.pdf

Welcome Lora Council

Fri, 24 Oct 2025 17:21:22 GMT

UASI Welcomes Lora Council, RHIA, CDIP, CCS, as Client Success Manager

UASI is pleased to announce that Lora Council, RHIA, CDIP, CCS has joined the team as Client Success Manager. Lora brings more than 16 years of experience in inpatient coding, auditing, and leadership, along with a strong record of improving quality and client outcomes.

Before joining UASI, Lora served as DRG Assistant Manager at Machinify (formerly Varis, LLC), where she led a team of coders, managed performance across multiple health plans, and drove initiatives that improved coding accuracy and compliance. She also spent over a decade at LexiCode Corporation in leadership roles focused on coding quality, education, and client relations.

Lora earned her Bachelor’s in Health Information Management from the University of Cincinnati and an Associate’s in Health Information Technology from Scott Community College. She holds AHIMA credentials as an RHIA, CCS, CDIP and a microcredential in Inpatient Coding Auditing. Lora is also an Adjunct Instructor in the Health Information Management Program at Eastern Iowa Community College, where she teaches ICD-10-PCS and Quality Management.

“I am excited to join UASI and contribute to a company that values quality, collaboration, and client success,” said Lora Council. “My focus has always been on accuracy, education, and partnership, and I look forward to supporting UASI’s mission of excellence in healthcare auditing and documentation.”

The addition of Lora Council reflects UASI’s continued commitment to strengthening its leadership team with experienced professionals who bring both technical expertise and a passion for client service. Her background in coding quality, education, and operations supports UASI’s mission to help healthcare organizations optimize performance, improve accuracy, and enhance patient care.

Beyond the Session: Key Takeaways from “The Nuances and Complexity of the Revenue Cycle Management of Critical Access Hospitals”

Wed, 22 Oct 2025 14:12:45 GMT

Beyond the Session: Key Takeaways on Revenue Cycle Management Challenges for Critical Access Hospitals

At the 2025 AHIMA Conference, Leah Jeffries, RHIT, CDIP, CCS, CCS-P, Managing Consultant at UASI, presented “The Nuances and Complexity of the Revenue Cycle Management of Critical Access Hospitals,” one of the most critical topics in rural healthcare. This session highlighted how Critical Access Hospitals (CAHs) sustain themselves in a complex regulatory and reimbursement environment and offered strategies for strengthening these lifelines of rural care.

For related insights on performance measurement and organizational support, see our quality and PSI solutions o verview.

Setting the Stage: Why CAHs Matter

Critical Access Hospitals are essential to improving healthcare access in underserved areas. Established under the Balanced Budget Act of 1997 to counter a wave of rural hospital closures, CAHs today provide inpatient, outpatient, swing-bed, and emergency services to communities that might otherwise face significant travel burdens or care gaps. They remain vital anchors for both healthcare delivery and local economies.

Eligibility and Conditions of Participation

CAHs operate under strict eligibility requirements: a rural location, no more than 25 inpatient beds, an average length of stay under 96 hours, and a defined minimum distance from other hospitals. They must also meet Conditions of Participation (CoP) that differ from acute-care hospitals, including medical staff bylaws, infection control programs, quality improvement initiatives, and state and federal documentation standards. These rules shape daily operations and define compliance expectations.

Revenue Cycle Management in Action

Understanding the nuances of cost-based reimbursement is critical to CAH financial health. Leaders must navigate inpatient, outpatient, and swing-bed payment structures while comparing Method I and Method II billing for professional services to maximize reimbursement. Special billing considerations—such as ambulance services, anesthesia, hospice, and swing-bed care—require careful management to avoid denials and protect revenue streams.

Common coding and billing pitfalls can erode financial stability if left unchecked. Swing-bed billing errors, anesthesia modifiers, ambulance mileage reporting, and charge validation issues are frequent pain points. Strengthening coder training, improving charge capture processes, and building tight feedback loops between coders, billers, and clinical staff can significantly improve accuracy and reduce denials.

Documentation and Compliance: Persistent Challenges

Clinical documentation is often the weakest link in CAHs due to limited staff, rotating providers, and hybrid paper/EHR systems. Common shortcomings include incomplete operative notes, delayed queries, outdated EHR smart phrases, and gaps in medical necessity documentation. Building stronger CDI programs, investing in provider education, and refining EHR tools can close these gaps and support compliant coding.

Surgical and anesthesia documentation also demand special attention. Missing signatures, absent start and stop times, and insufficient specificity can put reimbursement and compliance at risk. Structured templates, routine audits, and physician champions help reinforce best practices and ensure accountability.

Strategies for Success

Successful CAHs leverage data, communication, and training to drive improvement. Cross-training staff, collaborating with other rural facilities, and building community partnerships all strengthen resilience. Regular compliance briefings, simple visual dashboards for leadership, and alignment of financial strategies with clinical priorities are key to sustaining performance.

Preparing for Change: Regulatory Shifts and Rural Resilience

Regulatory and reimbursement changes are constant. Staying ahead requires proactive monitoring of CMS rules, ongoing staff education, and flexible technology solutions. With more than 140 rural hospitals having closed or stopped inpatient services since 2005, the stakes for CAHs have never been higher. Hospitals that anticipate and adapt to these changes can safeguard their reimbursement and maintain access to care for their communities.

Why It Matters

Critical Access Hospitals are more than healthcare providers—they are the backbone of rural communities, creating jobs, stabilizing local economies, and ensuring access to essential services. By adopting stronger revenue cycle practices, improving documentation, and staying current with regulations, healthcare leaders can maintain financial stability, regulatory compliance, and high-quality care close to home.

Final Thoughts

“The Nuances and Complexity of the Revenue Cycle Management of Critical Access Hospitals” highlights a roadmap for action. It offers tools and strategies for leaders to improve coding accuracy, strengthen documentation, and safeguard reimbursement even in resource-constrained environments.

Need Support?

UASI partners with hospitals and health systems to improve revenue cycle management, coding accuracy, and compliance. If your organization is looking to strengthen its processes or navigate the complexities of Critical Access Hospital requirements, our experts can help. Reach out to UASI today to learn how we can support your team.

Leah Jeffries, RHIT, CDIP, CCS, CCS-P

Managing Consultant, Strategy

Leah is a middle–revenue-cycle leader focused on improving coding operations, documentation quality, and financial performance through process redesign and technology-driven solutions. She excels at identifying root-cause issues, breaking down outdated workflows, and leading teams with transparency, collaboration, and hands-on problem solving. A featured speaker at the AHIMA 2025 Conference, Leah brings practical insight into modern middle–revenue-cycle challenges and solutions.

Her MBA equips her with a strong foundation in strategic thinking and organizational leadership, enabling her to align operational improvements with broader business objectives.

Works Cited

National Center for Biotechnology Information. (n.d.). Figure 22: Distribution of critical access hospitals in the United States, 2022. In 2022 National Healthcare Quality and Disparities Report. NCBI Bookshelf.
Available at https://www.ncbi.nlm.nih.gov/books/NBK601637/figure/ch1.fig22/

U.S. Department of Agriculture, Economic Research Service. (n.d.). 146 rural hospitals closed or stopped providing inpatient services from 2005 to 2023 in the United States. ERS Charts of Note.
Available at https://www.ers.usda.gov/data-products/chart-gallery/gallery/chart-detail/?chartId=103649

Centers for Medicare & Medicaid Services. (n.d.). Critical Access Hospitals.

Available at https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandsurveys/cah

Centers for Medicare & Medicaid Services. (n.d.). Medicare Claims Processing Manual, Chapter 2: Critical Access Hospitals.
Available at https://www.cms.gov/regulations-and-guidance/guidance/manuals/internet-only-manuals-ioms-items/cms018912

Centers for Medicare & Medicaid Services. (n.d.). Critical Access Hospitals Center.
Available at https://www.cms.gov/center/cah-center

Welcome Amanda Brodsky

Tue, 21 Oct 2025 12:52:44 GMT

UASI Welcomes Amanda Brodsky as Client Success Manager – Coding Services

UASI is thrilled to announce that Amanda Brodsky, CPC, COSC, has joined our team as Client Success Manager in Coding Services.

In this role, Amanda will partner closely with our clients to oversee service deliverables, manage engagement scope, and ensure exceptional quality and performance across our coding solutions. She will also collaborate with our internal teams to drive continuous improvement, optimize coding outcomes, and uphold our commitment to excellence in client success.

Amanda brings more than a decade of experience in medical coding, leadership, and team development. Before joining us, she served as a Coding Manager at Aquity Solutions, where she led multi-specialty coding teams, implemented productivity and quality initiatives, and maintained outstanding audit accuracy rates. Her proven leadership and dedication to client service make her a strong addition to our Coding Services team. Throughout her career, Amanda has advanced through several leadership and coding roles, building extensive experience across specialties such as Orthopedics, Pediatrics, and Pain Management.

Amanda is a Certified Professional Coder (CPC) and Certified Orthopaedic Surgery Coder (COSC) through AAPC. She also holds a Coaching & Teambuilding for Managers and Supervisors certification from SkillPath and earned her Bachelor of Science in Political Science and Government from Northern Illinois University.

“Amanda’s leadership experience and client-first mindset align perfectly with our mission to deliver high-quality, customized coding solutions,” said Donna Sherburne, Director of Coding Services. “We’re confident she will make an immediate and lasting impact for our clients and team members alike.”

We’re excited to welcome Amanda to the UASI team and look forward to the expertise and energy she brings to our organization.

Acute Kidney Injury (AKI)

Mon, 20 Oct 2025 16:37:30 GMT

Acute Kidney Injury (AKI)

Definition :

Acute Kidney Injury (AKI) is an abrupt decline in kidney function, leading to retention of waste products, electrolyte imbalance, and fluid dysregulation. It is classified based on etiology and severity. 

Types of AKI by Etiology 

Pre-Renal AKI  

Cause: Decreased renal perfusion without intrinsic kidney damage. 

Examples: 

Hypovolemia (dehydration, hemorrhage).
Hypotension/shock (sepsis, cardiogenic shock)
Heart failure, liver failure

Documentation Tip: Specify underlying cause (e.g., “AKI due to hypovolemia from GI bleed”). 

Intrinsic (Intra-Renal) AKI 

Cause: Direct damage to kidney tissue. 

Examples: 

Acute Tubular Necrosis (ATN\) – ischemia or nephrotoxins
Acute Interstitial Nephritis (AIN) – drug-induced, autoimmune
Glomerulonephritis

Documentation Tip: If ATN or AIN is suspected, document specifically (e.g., “AKI secondary to ATN from contrast exposure”).

Post-Renal AKI 

Cause: Obstruction of urine flow. 

Examples: 

Ureteral obstruction (stones, tumors)
Bladder outlet obstruction (BPH, neurogenic bladder)
Documentation Tip: State the obstructive cause (e.g., “AKI due to bilateral ureteral obstruction from stones”).

Diagnostic Criteria (KDIGO) 

Increase in serum creatinine by ≥ 0.3 mg/dL within 48 hrs, OR
Increase in serum creatinine to ≥ 1.5 times baseline within 7 days, OR
Urine output < 0.5 mL/kg/hr for 6 hrs

Severity Staging

Stage 1: 1.5–1.9 × baseline creatinine or ≥ 0.3 mg/dL rise
Stage 2: 2.0–2.9 × baseline
Stage 3: ≥ 3 × baseline or creatinine ≥ 4.0 mg/dL or dialysis required

CDI and Current Coding Guidance

Avoid vague terms like “renal insufficiency”; use “acute kidney injury” or “acute renal failure” (interchangeable per coding).
Always link AKI to the underlying cause (e.g., sepsis, dehydration, obstruction).
If ATN or AIN are present, document explicitly (these are MCCs).
Do not abbreviate AKI without context; clarify in the first mention.
Trend labs and urine output to support diagnosis before querying.
Assign code N17.0, Acute kidney failure with tubular necrosis, with a POA of N for documentation of a patient with AKI on admission who then develops ATN after admission.
For a case of acute kidney injury (AKI) due to acute tubular necrosis (ATN) secondary to contrast-induced nephropathy, the correct coding assignment is N17.0 for acute kidney failure with tubular necrosis, N14.11 for contrast-induced nephropathy, and T50.8X5A for adverse effect of diagnostic agents, initial encounter. This combination accurately reflects the underlying cause, the specific kidney injury type, and the adverse effect of the contrast agent.

Pro Tip:

AKI impacts severity of illness and quality metrics (e.g., PSI-10 Post-Op AKI). Accurate documentation ensures correct DRG assignment and patient safety.

Alyce Reavis, RN, MSN, CCDS, CCS

Senior CDI Educator, Consulting Services at UASI

Works Cited

AHA Coding Clinic. (2025). Third Quarter 2025, p. 22.

AHA Coding Clinic. (2022). Fourth Quarter 2022, p. 33.

Centers for Medicare & Medicaid Services. (2025). Official Guidelines for Coding and Reporting. Available at https://www.cms.gov

Fatehi, P., & Hsu, C.-Y. (2024). Evaluation of acute kidney injury among hospitalized adult patients. UpToDate.

Palevsky, P. M. (2025). Definition and staging criteria of acute kidney injury in adults. UpToDate.

Prescott, L., & Manz, J. (2025). The ACDIS Inpatient CDI Pocket Guide. Available at https://www.acdis.org

Accurate Egg Allergy Coding

Thu, 09 Oct 2025 18:41:31 GMT

Accurate Egg Allergy Coding

With the FY 2026 update, ICD-10-CM adds more specificity for egg allergies and reactions — especially distinguishing tolerance vs reactivity to baked egg.

Here are the key new (or revised) codes:

T-codes (for adverse reactions / anaphylaxis) - These go in Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (T66–T78 etc.):

* “X” is a placeholder for the 7th character (A = initial, D = subsequent, S = sequela).

So, the prior “umbrella” codes for anaphylaxis or adverse food reaction due to eggs, are being deleted or replaced in favor of more detailed ones.

Z-codes (allergy status / history codes)

These go in Chapter Z (Factors influencing health status) , under “Allergy status, other than to drugs and biological substances”:

Z91.0120 — Allergy to eggs, unspecified
Z91.0121 — Allergy to eggs with tolerance to baked egg
Z91.0122 — Allergy to eggs with reactivity to baked egg

These Z-codes reflect a patient’s allergy status or history , not necessarily an acute reaction but recognition that the allergy exists (and whether they tolerate or react to baked egg).

The old parent code Z91.012 (“Allergy to eggs”) is being deleted / replaced by this more granular trio.

What This Means in Practice & Documentation Tips

To code correctly under the new scheme:

Know whether it's an acute reaction or just allergy status.

If it's an acute allergic reaction / anaphylaxis / other reaction , use a T-code .
If it's merely documenting a known allergy status or history , use a Z-code .

Specify baked egg tolerance/reactivity if known.
The key new distinction is whether the person tolerates baked egg or has a reaction to baked egg (versus unspecified). Any documentation you have should note baked egg status (e.g. “patient tolerates baked egg,” or “patient has reactions to baked egg”) to allow assigning the more specific code.

Select the correct 7th character for T-codes.

A = initial encounter
D = subsequent (follow-up)
S = sequela (late effect)
Make sure your documentation reflects timing and encounter context.

Avoid using the old generic codes once deleted.
Old umbrella codes (e.g. T78.08XX for eggs, T78.1 for other adverse food reactions) will be invalid for claims after October 1, 2025.

Query when needed.
If the record doesn't specify whether the reaction was to baked egg or tolerance versus reactivity, query the provider for clarity so you can pick the correct new code rather than default to “unspecified.”

Check consistency with clinical notes and allergy testing.
Lab results, allergy challenge notes, or physician narrative may help you determine baked egg status.

Tracy Blevins, MSHIM, RHIA

Senior Consultant, Audit at UASI

Works Cited

American Academy of Allergy, Asthma & Immunology. (2025, September). 2026 code updates.
Available at https://college.acaai.org/2026-code-updates/

Association of Clinical Documentation Integrity Specialists (ACDIS). (2025). CMS releases FY 2026 ICD-10-CM code update.
Available at https://acdis.org/articles/news-cms-releases-fy-2026-icd-10-cm-code-update

Centers for Medicare & Medicaid Services. (2025). FY 2026 ICD-10-CM Official Guidelines for Coding and Reporting.
Available at https://www.cms.gov/files/document/fy-2026-icd-10-cm-coding-guidelines.pdf

Inflammatory Breast Cancer (IBC)

Thu, 09 Oct 2025 18:33:36 GMT

Inflammatory Breast Cancer (IBC) Coding Tip

New ICD-10 Codes for Inflammatory Breast Cancer (IBC) – Effective October 1, 2025

As of October 1, 2025, three new ICD-10 codes are now available for use to improve accuracy in reporting Inflammatory Breast Cancer (IBC). Coders should begin applying these codes to ensure precise documentation and compliance with current coding standards.

C50.A0 – Malignant inflammatory neoplasm of unspecified breast
Used when documentation confirms inflammatory breast cancer (IBC) but does not specify which breast is affected; supports accurate reporting when laterality is not documented.
C50.A1 – Malignant inflammatory neoplasm of left breast
Identifies confirmed inflammatory breast cancer involving the left breast, allowing precise coding that reflects the disease’s location and aids in treatment tracking.
C50.A2 – Malignant inflammatory neoplasm of right breast
Used to report inflammatory breast cancer of the right breast, improving data accuracy for diagnosis, outcomes monitoring, and research purposes.

Clinical Presentation and Challenges in Diagnosing Inflammatory Breast Cancer

IBC is a rare but aggressive form of breast cancer, accounting for approximately 1–5% of cases in the U.S. Unlike typical breast cancers, IBC often presents without a detectable lump. Instead, symptoms include:

Skin changes such as redness, swelling, or bruising
“Peau d’orange” texture (pitted skin resembling an orange peel)
Tenderness or burning sensation

Due to its atypical presentation, IBC is frequently misdiagnosed as mastitis and often detected at advanced stages (III or IV). It disproportionately affects women under 40, particularly African American and Black women, and is associated with excess body weight.

Previously, providers had limited options for coding IBC, often defaulting to malignancy by site breast cancer codes without specifying type. These new codes will enhance clinical documentation, support better tracking of disease progression, and improve access to appropriate treatment.

Thanks to advocacy efforts by the IBC Research Foundation and Susan G. Komen, these updates aim to improve data collection and advance research.

Melanie Perrault, RHIA, CDIP, CCS

Senior Consultant, Audit at UASI

Works Cited

Susan G. Komen. (n.d.). IBC Provider Guide.
Available at https://www.komen.org/wp-content/uploads/IBC_Guide_082824.pdf

Coding Tip: Drug and Alcohol Use

Thu, 09 Oct 2025 18:26:50 GMT

Drug and Alcohol Use Coding Tip

When to Code Recreational Drug and Alcohol Use

With many states legalizing marijuana, “recreational marijuana use” has been appearing in physician documentation more frequently. Is this coded regularly in the same way that drug abuse and dependence is?

The answer is in the coding guidelines for Chapter 5 in Section II.5.b.3 “the codes for unspecified psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-,F15.9-, F16.9-, F18.9-, F19.9-)… are to be used only when the psychoactive substance use is associated with a substance related disorder (chapter 5 disorders such as sexual dysfunction, sleep disorder, or a mental or behavioral disorder) or medical condition, and such a relationship is documented by the provider.” This guideline means that merely the documentation of drug/alcohol use alone is not enough to require coding. A good example of when alcohol use would be coded is if a patient has alcoholic cirrhosis and only alcohol use is documented. The alcohol use would be coded since there is an associated medical condition as described in the guideline. Coding clinic 2nd quarter 2018 pg 11 provides further guidance on recreational marijuana use.

Coding Recreational Drug Use in Pregnancy

Coding drug use in a pregnant patient, however, requires different guidelines:

Per coding clinic 2nd quarter 2018 pgs 10-11 the drug use complicating pregnancy is coded for any drug use during pregnancy. Per the coding guidelines “It is the provider’s responsibility to state that the condition being treat is not affecting the pregnancy”.

Drug use DISORDER is a different diagnosis and is coded differently:

Per coding guideline Section II.5.b.1 “mild substance use disorders… are classified to the appropriate codes for substance abuse…and moderate or severe substance use disorders…. are classified to the appropriate codes for substance dependence.” Therefore, we have guidance that if mild drug use disorder is documented we code this as drug abuse, and if moderate or severe drug use disorder is documented we code this as drug dependence. The same applies to alcohol. If drug use disorder is documented without a severity, we cannot assume the severity and a query must be placed.

Kendra Adams, RHIT

Senior Consultant, Audit at UASI

With a strong background in health information technology and ICD-10 coding, Kendra Adams serves as a Senior Consultant in Audit at UASI. She contributes clear, practical coding tips rooted in real-world audit work to help coders improve accuracy, documentation quality, and compliant code assignment.

Works Cited

American Hospital Association. (n.d.). AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS.
Available at https://www.codingclinicadvisor.com/ – the official portal for AHA Coding Clinic guidance and newsletters on ICD-10-CM/PCS updates and advice.

Centers for Medicare & Medicaid Services & National Center for Health Statistics. (2024). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2025 (effective October 1, 2024).
Available at https://www.cms.gov/files/document/fy-2025-icd-10-cm-coding-guidelines.pdf

What to Expect at AHIMA 2025: A First Look at The Nuances and Complexity of the Revenue Cycle Management of Critical Access Hospitals

Wed, 01 Oct 2025 16:49:53 GMT

AHIMA 2025 Preview: Exploring Revenue Cycle Challenges for Critical Access Hospitals

Rural hospitals are lifelines for millions of Americans but face unique operational, financial, and regulatory challenges. At the 2025 AHIMA Conference, Leah Jeffries, RHIT, CDIP, CCS, CCS-P, Managing Consultant at UASI, will present “The Nuances and Complexity of the Revenue Cycle Management of Critical Access Hospitals.”

For related insights on performance measurement and organizational support, see our PSI and Quality Solutions overview.

This session explores how Critical Access Hospitals (CAHs), small rural facilities designated by CMS, operate under different rules than larger hospitals. With up to 25 inpatient beds, distinct Conditions of Participation, and cost-based reimbursement, CAHs must balance strict requirements with financial stability while serving underserved communities.

Key Takeaways

Learn the history, purpose, and eligibility criteria of CAHs, including cost-based reimbursement and flexible billing options.
Understand how Conditions of Participation differ from acute-care hospitals, covering bylaws, quality programs, infection control, and documentation standards.
Explore cost-based reimbursement for inpatient, outpatient, and swing-bed services plus Method I and II billing for professional services.
Discover common coding pitfalls unique to CAHs, from swing-bed and ambulance coding to anesthesia modifiers and charge validation.
Gain strategies to improve documentation, reduce denials, and strengthen compliance despite limited resources.

Looking Ahead
There will also be a review recent and upcoming regulatory changes shaping rural healthcare. With over 140 rural hospitals having closed since 2005, attendees will leave equipped to protect reimbursement, improve revenue cycle processes, and sustain access to care.

Critical Access Hospitals are more than healthcare providers; they are anchors for rural economies. This session offers actionable strategies to help CAHs thrive despite unique challenges.

If you work in revenue cycle management, health information management, compliance, or clinical documentation, this is a must-attend session at AHIMA 2025.

Works Cited:

Leah Jeffries, RHIT, CDIP, CCS, CCS-P

Managing Consultant, Strategy at UASI

Reporting of Firearm Injury Intent

Tue, 30 Sep 2025 14:45:37 GMT

CDI Tip: Reporting Firearm Injury Intent from Other Clinicians’ Documentation

What’s New in FY 2026?

CMS and ICD-10-CM guidelines now allow documentation by clinicians other than the patient’s provider (e.g., nurses, social workers, trauma team) to be used for assigning external cause codes, including firearm injury intent.
This change supports more accurate public health reporting and injury surveillance

Key Actions for CDI Specialists

Review All Clinical Notes
Check ED notes, nursing assessments, social work documentation, and EMS reports for statements about firearm injury intent (e.g., accidental, assault, self-harm, undetermined).
Apply the New Intent Hierarchy
If intent is clearly documented by any clinician, code accordingly:
Accidental: W34 series
Assault: X93–X95 series
Self-harm: X72–X74 series
Undetermined: Y22–Y24 series
If no intent is documented, follow the updated guideline: default to undetermined intent for firearm injuries (Y24.9), unless otherwise specified.
Query When Needed
If conflicting documentation exists (e.g., ED note states “possible assault,” nursing note says “accidental”), query the provider for clarification.
Document Source
When coding based on another clinician’s note, ensure the documentation is clearly attributed in the record.

Pro Tip: Incorporate firearm injury intent review into your trauma and ED CDI workflows. Educate providers that intent matters for coding, quality metrics, and injury prevention programs.

Example Clinical Scenario with Query:

Setting: ED, trauma bay

Patient: 28-year-old male with a through and through gunshot wound of the left thigh; hemodynamically stable.

Documentation in record:

ED triage RN note: “Pt states he was shot by someone outside a bar.”
EMS run sheet: “Bystanders report drive by shooting; single GSW to L thigh.”
ED SW note: “Patient reports unknown assailant; denies self-harm.”
ED provider note: “GSW L thigh; hemorrhage controlled; analgesia given.” Intent not specified in provider note or discharge summary

Query:

Documentation in the medical record shows that the patient was injured by a firearm. Please clarify the intent of the firearm injury for this encounter, based on your clinical judgment and the medical record.

Assault (injury inflicted by another person)
Accidental/unintentional
Intentional self-harm
Undetermined (unable to determine intent from available information)
Other (please specify): _______________________

Alyce Reavis, RN, MSN, CCDS, CCS

Senior CDI Educator, Consulting Services at UASI

Works Cited

Centers for Medicare & Medicaid Services. (2025). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026.

Available at https://www.cms.gov/files/document/fy-2026-icd-10-cm-coding-guidelines.pdf

Centers for Medicare & Medicaid Services. (2023). Improving the collection of social determinants of health data with ICD-10-CM “Z” codes. Available at https://www.cms.gov/files/document/cms-2023-omh-z-code-resource.pdf

Health in Context: Understanding the Impact of Social Determinants of Health (SDoH)

Mon, 29 Sep 2025 14:42:29 GMT

Health in Context: Understanding the Impact of Social Determinants of Health (SDOH)

Summary of a Presentation by Rachel Mack, MSN, RN, CCDS, CDIP, CCS, CRC at the 2025 CHIMA Annual Meeting

What Are Social Determinants of Health?

Social Determinants of Health are defined by the Healthy People 2030 initiative as the conditions in which people are born, live, learn, work, play, worship, and age. These factors shape a wide range of health risks and outcomes. While medical care accounts for roughly 20 percent of an individual’s overall health, more than half is influenced by non-medical factors such as housing stability, income, education level, food access, and transportation.

Historically, the connection between social conditions and health outcomes has been well-documented, including landmark studies like the Whitehall reports. In recent years, the healthcare industry has begun codifying these insights. Since 2016, the ICD-10-CM coding system has introduced and expanded the use of Z codes to document SDoH, with recent updates in 2024 further elevating their importance. Notably, CMS has begun assigning severity designations to some SDoH codes, signaling recognition of the financial and clinical impact of unmet social needs.

The Real-World Impact of SDoH

Understanding SDoH is essential for improving individual and population health. In a global snapshot, if the world were represented by 100 people, 22 would lack shelter, 11 would be undernourished, and just 7 would have college degrees. These statistics reflect how social conditions shape access to care, outcomes, and quality of life.

Disparities in chronic conditions such as asthma, diabetes, and hypertension are often mistakenly attributed solely to race. In reality, social factors like access to nutritious food, safe housing, transportation, and exposure to stress or environmental toxins play a much larger role in determining risk and resilience.

Using ICD-10-CM Z Codes to Capture SDoH

Capturing SDoH through appropriate ICD-10-CM Z codes is becoming an increasingly important function for clinical documentation integrity (CDI) teams, coders, and healthcare organizations. Codes in categories Z55 through Z65 cover education, employment, housing, psychosocial circumstances, upbringing, and the physical environment.

Per current guidelines, these codes can be assigned based on documentation by clinicians or other providers if the information is signed off and included in the health record. It is important to ensure that the documentation reflects actual risk factors or impacts on care. For example, a patient without a vehicle may not necessarily face transportation insecurity if they have access to reliable public transit. Conversely, documented housing instability or food insecurity should be captured when it affects health outcomes or the care plan.

Assigning multiple Z codes as needed helps to fully represent the patient’s context and allows for a more accurate reflection of their needs and challenges.

Understanding the 9 SDoH Z Code Categories

ICD-10-CM includes nine categories of SDoH-related Z codes (Z55–Z65), each representing a unique aspect of a patient’s environment or circumstances. These categories are not just data points—they are actionable indicators that can inform care planning, risk adjustment, and health equity strategies:

Z55 – Problems Related to Education and Literacy
Includes low literacy, lack of schooling, or barriers to learning. These factors can affect the ability to understand care plans or manage chronic conditions.
Z56 – Problems Related to Employment and Unemployment
Encompasses job loss, unsafe work environments, and low income. These are tied to stress, mental health, and insurance coverage issues.
Z57 – Occupational Exposure to Risk Factors
Includes exposure to noise, toxic agents, or other work-related health hazards. Often overlooked, these codes can support worker compensation and care coordination.
Z58 – Problems Related to Physical Environment
Captures exposure to pollution, unsafe housing, or lack of green space. Environmental factors are closely tied to respiratory and cardiovascular health.
Z59 – Problems Related to Housing and Economic Circumstances
Includes homelessness, food insecurity, inadequate housing, and utility difficulties. These are among the most commonly captured SDoH codes and have high clinical relevance.
Z60 – Problems Related to Social Environment
Encompasses social isolation, lack of support, and difficulty with community integration. These factors can influence mental health and medication adherence.
Z62 – Problems Related to Upbringing
Includes issues such as neglect, abuse, or exposure to domestic violence. These are particularly important in pediatric and behavioral health settings.
Z63 – Other Problems Related to Primary Support Group
Addresses disruptions in caregiving roles, family stress, and absent family members. Critical in care transitions and discharge planning.
Z64–Z65 – Other Psychosocial and Socioeconomic Circumstances
Encompasses problems related to unwanted pregnancy, legal issues, and other life stressors. Often documented by behavioral health or case management teams.

Each of these categories reflects different but intersecting dimensions of a person’s lived experience. When documented and coded correctly, they can drive referrals to support services, justify length-of-stay variances, influence readmission risk scoring, and strengthen a health system’s community investment strategy.

Challenges and Opportunities in SDoH Documentation

Although the value of SDoH data is widely acknowledged, several challenges remain in capturing it consistently. Many Z codes are not directly tied to reimbursement, which can discourage thorough documentation. Electronic medical records often lack optimized workflows for social data, and CDI technology may overlook valuable information entered by non-provider clinicians such as social workers or dietitians.

Innovative solutions are emerging to bridge these gaps. For instance, integrated note templates can automatically pull social risk details into provider documentation. In one example, a dietitian’s note identifying both food insecurity and cachexia enabled accurate coding and more complete reflection of the patient’s condition, which had downstream effects on quality metrics and resource planning.

Looking Forward: Building Infrastructure for SDoH

Integrating SDoH into clinical documentation and coding is not just a data initiative—it is a foundational step toward delivering equitable, patient-centered care. Moving forward, cross-functional collaboration among providers, social workers, case managers, dietitians, pharmacists, and other care team members will be essential. Broad-based education on documentation practices and coding guidelines will support this effort.

Federal initiatives are also pushing for more coordinated care that includes social risk assessment and intervention. These efforts aim to embed social care into medical care models and encourage providers to address SDoH proactively, both for compliance and for community impact.

Capturing SDoH data accurately and consistently allows health systems to identify gaps, design better interventions, and drive measurable improvement in outcomes. Ultimately, understanding health in its full context—social, economic, and environmental—is essential to transforming the healthcare system.

Rachel Mack, MSN, RN, CCDS, CDIP, CCS, CRC

Managing Consultant, CDI at UASI

Works Cited

Centers for Medicare & Medicaid Services. (2025). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2025 (Updated April 1, 2025).

Available at https://www.cms.gov/files/document/fy-2025-icd-10-cm-coding-guidelines.pdf

Journal of AHIMA. (n.d.). Data reporting limitations need to be addressed when including SDOH Z codes on medical claims.
Available at https://journal.ahima.org/page/data-reporting-limitations-need-to-be-addressed-when-including-sdoh-z-codes-on-medical-claims

UpToDate. (n.d.). Use of race and ethnicity in medicine.
Available at https://www.uptodate.com/contents/use-of-race-and-ethnicity-in-medicine

Centers for Medicare & Medicaid Services. (n.d.). Utilization of Z codes for social determinants of health.
Available at https://www.cms.gov/files/document/z-codes-data-highlight.pdf

Reporting the Calyxo SURE Procedure with CVAC System

Fri, 26 Sep 2025 16:27:09 GMT

Reporting the Calyxo SURE Procedure With the CVac System: Clinical Documentation and Coding Guidance

Overview of the Calyxo Sure Procedure and CVac System

The SURE Procedure (Steerable Ureteroscopic Renal Evacuation) is a minimally invasive technique for kidney stone management using the Controlled Vacuum Assisted Clearance (CVAC) system. This single-use device enables continuous irrigation and aspiration during laser lithotripsy, enhancing stone fragment clearance from the renal collecting system.

Example of operative note:

“Following laser lithotripsy, a steerable CVAC catheter was introduced via access sheath. Under fluoroscopic guidance, microjet irrigation and aspiration were performed to evacuate stone fragments into the collection canister. Clearance confirmed endoscopically.”

Billing Information for Physicians

To report a cystoscopy with ureteroscopy and laser lithotripsy with steerable vacuum stone extraction for renal and/or ureteral stone, it would be appropriate to report code 52353, Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included).

Based on the CPT guidance above, if there was an insertion of a stent during this procedure, you would report code 52356 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (e.g. Gibbons or double-J type)

The device manufacturer recommends considering the use of CPT code 53899 ( Unlisted procedure, urinary system ) to represent the steerable vacuum aspiration of the kidney , in conjunction with either 52353 or 52356 , depending on the procedure details. However, CPT guidance has not formally endorsed or confirmed this coding approach as of this time. The removal of the stone fragments are inclusive to the 52353 and 52356 procedure codes. If there is documentation of extra effort and time beyond the normal, modifier 22 may be applicable. As always, consult your payer reimbursement policies.

Billing Information for Outpatient Facility/Ambulatory Surgery Center

Use the HCPCS code C9761 Cystourethroscopy, with uteroscopy and/or pyeloscopy, with lithotripsy, and ureteral catheterization for steerable vacuum aspiration of the kidney, collecting system, ureter, bladder, and urethra if applicable (must use a steerable ureteral catheter)

The Device Code is C1741 Endoscope, single-use (i.e. disposable), urinary tract, imaging/illumination device (insertable)

Melanie Perrault, RHIA, CDIP, CCS

Senior Consultant, Audit at UASI

Works Cited

Calyxo, Inc. (n.d.). Calyxo SURE Procedure.
Available at https://calyxoinc.com/calyxo-sure-procedure/Calyxo

American Medical Association (AMA). (2025, February). CPT Assistant, 35(2), 28.
Available at https://www.ama-assn.org/practice-management/cpt

Capturing Social Determinants of Health (SDOH) in Inpatient Coding

Fri, 26 Sep 2025 16:20:26 GMT

Capturing Social Determinants of Health (SDOH) in Inpatient Coding

Social Determinants of Health (SDOH) play a major role in patient outcomes and are increasingly important in value-based care and quality reporting. CMS and payers are leveraging SDOH codes to measure population health, address equity, and adjust risk. For coders, this means capturing SDOH in inpatient records has never been more impactful.

ICD-10-CM Z Codes for Social Determinants of Health (Z55–Z65)

The ICD-10-CM Z55–Z65 category includes codes that describe social risk factors such as housing instability, food insecurity, lack of transportation, and financial hardship. While these factors may not always affect DRG assignment directly, they provide critical insight into patient care complexity and resource needs.

Common Pitfalls When Documenting SDOH in Inpatient Coding

Assuming SDOH doesn’t matter for inpatient cases: These codes may influence risk adjustment and quality metrics, even if they don’t change DRG assignment.

Overlooking non-provider documentation: Coders can use SDOH documented by clinicians other than the physician (e.g., nurses, case managers, social workers), per official guidelines.

Incomplete capture: Many records include valuable SDOH information in case management or discharge planning notes that coders may overlook.

Example of SDOH Documentation and Z-Code Assignment

Documentation: Case manager notes that the patient has “housing instability” and lacks access to medications due to cost.

Assign: Z59.01 – Sheltered homelessness (if specified) or Z59.89 – Other problems related to housing and economic circumstances.
Assign: Z59.6 – Low income if financial hardship is documented. These codes do not shift DRG, but they support accurate risk adjustment and better reflect the patient’s care needs.

Actionable Tips:

Always review social work, case management, and discharge planning notes for SDOH documentation.
Capture all relevant SDOH Z-codes when documented by qualified healthcare team members.
Educate providers and staff on the importance of documenting SDOH clearly and consistently.
Remember: While SDOH may not change the DRG, they support value-based care models and health equity initiatives.

Jessica Lutz, MBA, RHIA, CCS
AHIMA Microcredential: Auditing: Inpatient Coding

Senior Consultant, Audit at UASI

Works Cited

Centers for Medicare & Medicaid Services. (2023). Social determinants of health (SDOH) Z codes.

Centers for Medicare & Medicaid Services. (2025). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2025 (Updated April 1, 2025). Available at https://www.cms.gov/files/document/fy-2025-icd-10-cm-coding-guidelines.pdf

ICD-10-PCS Coding Clarification: Transcalvarial Mass Biopsies

Fri, 26 Sep 2025 16:15:29 GMT

ICD-10-PCS Coding Clarification for Transcalvarial Mass Biopsies

Overview of Transcalvarial Mass Biopsies

In neuroimaging, “extra-axial” doesn’t mean outside the skull, it means outside the brain parenchyma (the brain tissue itself) but still inside the skull.

Intra-axial = within the brain tissue (e.g., gliomas, abscesses).
Extra-axial = outside the brain tissue but within the cranial cavity (e.g., meningiomas, metastases on the dura, arachnoid cysts, subdural hematomas).

So: Outside the skull would be extracranial. Extra-axial means the lesion is intracranial but not in the brain substance.

A simple way to remember:

Axial = brain substance
Extra-axial = outside the brain substance, but inside the head

Looking further into a Transcalvarial mass – A transcalvarial mass is a lesion that extends through the calvarium (skull bones), connecting the intracranial (inside the skull) compartment with the extracranial (outside the skull) space.

Key points:

The calvarium = the dome-like skull bones that encase the brain.
"Transcalvarial" = crossing through the calvarium.

Seen with aggressive tumors, metastases, or sometimes infections that erode bone. Imaging will often show a continuous mass that breaches both the inner and outer tables of the skull. So, compared to extra-axial (inside skull, outside brain), a transcalvarial mass goes a step further — it escapes the skull.

How Transcalvarial Mass Biopsies Are Classified in ICD-10-PCS

This is one of those “it depends” situations in coding, because a transcalvarial mass spans both intracranial and extracranial compartments.

General coding logic: Intracranial procedures (craniotomy/craniectomy approaches, brain or meningeal biopsies) are coded under intracranial biopsy codes.

Extracranial procedures (scalp, subcutaneous, or skull-only masses) are coded with extracranial biopsy codes.

Biopsy Site as the Determining Factor for PCS Code Selection

If the surgeon biopsies the intracranial portion (inside the dura or cranial cavity) → code as intracranial.

Some Examples:

00B00ZX – Excision of brain, open approach, diagnostic.
00B73ZX – Excision of cerebral hemisphere, percutaneous approach, diagnostic.
00B24ZX – Excision of dura mater, percutaneous endoscopic approach, diagnostic.

If the biopsy is from the extracranial portion (outside the skull or superficial component) → code as extracranial.

Some Examples:

0JB00ZX – Excision of scalp subcutaneous tissue and fascia, open approach, diagnostic.
0HB1XZX – Excision of facial skin, external approach, diagnostic.
0QB00ZX – Excision of skull (cranial bone), open approach, diagnostic.

If documentation doesn’t specify, query the provider, because the coding pathway hinges on the biopsy site.

Tracy Blevins, MSHIM, RHIA

Senior Consultant, Audit at UASI

Works Cited

Centers for Medicare & Medicaid Services. (2025). ICD-10-PCS Official Guidelines for Coding and Reporting.
Available at https://www.cms.gov/files/document/2025-official-icd-10-pcs-coding-guidelines.pdf

American Hospital Association. (2017). Biopsy coding when lesions cross boundaries. Coding Clinic for ICD-10-CM/PCS, Fourth Quarter, 28–29.

American Hospital Association. (n.d.). Coding Clinic for ICD-10-CM/PCS.
Available at https://www.ahacentraloffice.org/aha-coding-clinic

Ventricular Standstill

Mon, 22 Sep 2025 19:33:57 GMT

Ventricular Standstill: Clinical Documentation and Coding Considerations

What is ventricular standstill?

SA node is functioning, and P waves are present on EKG.
There is no ventricular response, no contractions of the muscle.
The presence of complete heart block with no escape rhythm.
No cardiac output with the patient in full arrest.
May be paroxysmal or prolonged.

Why Ventricular Standstill Is Clinically Significant

It is a potentially fatal arrhythmia.
The ventricles come to a complete standstill.
Sustained for more than a few seconds, unconsciousness and no palpable pulse.
Sustained is considered an unshockable rhythm, 10X more deadly than V-fib.
Immediate CPR required with likely placement of a pacemaker.

Clinical Documentation Tips for Ventricular Standstill

1.) Document the Underlying Cause

Review and query if needed for contributing factors such as:
Electrolyte imbalances (e.g., hyperkalemia, hypokalemia)
Drug toxicity (e.g., cocaine overdose)
Cardiac conditions (e.g., advanced AV block)
Non-cardiac causes (e.g., hypoxia, acidosis)

2.) Clinical Indicators

Support the diagnosis:
ECG findings (e.g., isolated P waves, absence of QRS)
Symptoms (e.g., syncope, loss of consciousness, pulselessness)
Treatment response (e.g., CPR, pacemaker insertion)

3.) Specify the Type of Block

If applicable, clarify whether the patient has:
Complete AV block
Trifascicular block
Sub-Hisian block (more life-threatening)

4.) Treatment Documentation

Note any interventions:
CPR
Temporary or permanent pacemaker
Medications (e.g., epinephrine)

5.) Avoid Ambiguity

Review for precise terminology. Avoid vague phrases like “heart stopped” or “no rhythm” without correlating ECG or clinical context

Coding Considerations

1.) Primary Code

I46.9 – Cardiac arrest, unspecified (Classifies as MCC when patient is discharged alive)

2.) ICD-10-CM Alphabetic Index

3.) Current Coding Guidance:

When complete/3rd degree heart block is present with asystole in the instance of a brief pause of electrical conduction with spontaneous recovery of sinus rhythm, the asystole is likely caused by the complete heart block. Therefore, only I44.2 is assigned and not reported with the code for cardiac arrest.
What does this specifically mean for CDI and Coding? It means we can't code third degree/complete heart block and ventricular standstill together.

Documentation Example:

Received page for prolonged AV block. Tele strip shows p waves with ventricular standstill for 19 seconds. Patient is asymptomatic with normal BP at time of arrhythmia. Received IV metoprolol 2.5 mg and now scheduled Q6H for PAF. No other nodal blocking agents. Electrolytes are unremarkable today. TTE was normal this admission.

Alyce Reavis, RN, MSN, CCDS, CCS

Senior CDI Educator, Consulting Services at UASI

Works Cited

Association of Clinical Documentation Integrity Specialists & American Health Information Management Association. (2022). Guidelines for achieving a compliant query practice.

American Hospital Association. (2019). Complete heart block and asystole. Coding Clinic for ICD-10-CM/PCS, Second Quarter, 4.

Centers for Medicare & Medicaid Services. (2025). ICD-10-CM Official Guidelines for Coding and Reporting.
Available at https://www.cms.gov/medicare/coding/icd10

ICD-10-CM Code Book. (2025).

Prutkin, J. (2024). ECG tutorial: Miscellaneous diagnoses. UpToDate.
Available at https://www.uptodate.com/contents/ecg-tutorial-miscellaneous-diagnoses

University of New Mexico. (n.d.). Ventricular standstill.
Available at https://www.ekgstripsearch.com/Vent_SS.htm

Welcome Autumn Reiter

Fri, 19 Sep 2025 13:11:47 GMT

UASI is proud to announce the appointment of Autumn Reiter as Chief Strategy and Solutions Officer. With 20 years of nursing experience, an MBA, and a decade of leadership in revenue cycle, payment integrity, and documentation improvement, Autumn brings a rare blend of clinical insight and strategic business expertise to the role.

Autumn brings 20+ years of experience leading teams and delivering large scale solutions in CDI and Tech Enablement, Payment Integrity, and Provider Risk Strategies. Throughout her career, she has led large-scale programmatic builds, developed innovative solutions to optimize revenue capture, and implemented operational efficiencies that improved compliance and reduced costs for healthcare organizations nationwide.

“UASI’s reputation for delivering exceptional results through strategic mid-revenue cycle solutions is unmatched in the industry,” said Reiter. “I am excited to join a team that shares my passion for bridging clinical care and business operations to drive quality, compliance, and operational excellence in healthcare reimbursement.”

The addition of Autumn Reiter reflects UASI’s ongoing commitment to expanding its leadership team with seasoned industry experts who are dedicated to helping clients strategically optimize their revenue cycle, streamline operations, and enhance patient care.

About UASI

For over 40 years, UASI has bridged the gap between people and processes in financial and clinical operations by providing solutions that reduce revenue leakage, enhance operational efficiency, and ensure quality and compliance.

Converting Denials into Higher Star Ratings

Tue, 16 Sep 2025 14:37:50 GMT

Why CMS Star Ratings Matter More Than Ever

Hospitals are constantly measured on their quality of care, but few metrics carry as much weight as the Centers for Medicare & Medicaid Services (CMS) Star Ratings. These ratings influence how patients choose hospitals, how payers negotiate contracts, and how organizations position themselves in an increasingly competitive healthcare landscape.

The Role of Star Ratings

The CMS Star Ratings program evaluates hospitals across a wide range of quality measures . These include clinical outcomes such as readmissions and mortality, safety indicators like hospital-acquired conditions, and patient experience surveys addressing communication, responsiveness, and cleanliness. Hospitals receive an overall score that is highly visible to the public and payers.

Impact on Patient Choice and Public Perception

Patients want assurance that the care they receive will be safe and effective. Star Ratings serve as a shorthand for quality, guiding patient choice when selecting where to receive treatment. Hospitals with higher ratings often enjoy stronger reputations in their communities, while lower ratings can raise concerns about safety and performance.

Influence on Reimbursement and Contracts

Star Ratings are not just symbolic. They affect how hospitals are reimbursed, influence payer negotiations, and may unlock incentive payments for high performance. For many organizations, Star Ratings directly shape financial sustainability and the ability to reinvest in staff and technology.

The Hidden Impact of Denials on Star Ratings

Denials are often seen as a revenue cycle issue, but their impact goes far beyond delayed payments. When denials distort clinical data, they also undermine a hospital’s performance in CMS Star Ratings.

Financial Consequences

Every denied claim represents lost or delayed revenue. This directly reduces the resources available for quality initiatives, staffing, and patient experience improvements. Hospitals under financial strain may struggle to invest in areas that strengthen Star Ratings.

Data Accuracy and Risk Adjustment

Denials linked to documentation gaps or coding errors can lead to underreporting of patient complexity. Missed severity of illness and comorbidities affect risk adjustment, making outcomes such as mortality or readmissions appear worse than they are. Inaccurate data paints an incomplete picture of care quality.

Denials influence critical Star Ratings measures, including:

Mortality rates
Readmission rates
Complications
Patient safety indicators

When denials obscure true performance, hospitals risk lower ratings despite providing high-quality care.

Operational Burden

Staff rework and appeals consume time that could otherwise be dedicated to patient care, CDI initiatives, and proactive quality improvements. This operational distraction further hampers performance on Star Ratings measures.

Organizations that do not address denial management place both their financial health and their public reputation at risk. By taking a proactive and comprehensive approach to denial prevention and management, hospitals can improve patient outcomes, protect vital revenue streams, and reinforce the trust and confidence of their communities and stakeholders.

Turning Denial Prevention into Star Ratings Success

Reducing denials is about more than revenue recovery. It is a strategic opportunity to strengthen documentation, improve data accuracy, and ultimately elevate CMS Star Ratings.

Key Risks to Address

Hospitals that do not proactively manage denials face three major risks:

Missed capture of severity of illness and risk adjustment
Underreported quality outcomes
Reduced ability to invest in staff, technology, and patient experience

Strategic Priorities for Hospitals

Strengthen Documentation and Coding Accuracy: Clear, complete provider documentation ensures accurate code assignment and proper reflection of patient complexity.
Proactively Manage Denials and Appeals: Early intervention prevents errors from cascading into distorted data and reduced reimbursement.
Align CDI, Coding, and Revenue Cycle with Quality Measures: Collaboration across these functions ensures accurate reporting of outcomes and supports better ratings.
Reinforce the Cycle of Accuracy: Accurate documentation leads to improved reimbursement, which enables reinvestment in quality initiatives, ultimately driving higher Star Ratings

Connecting Quality and Finance
Denial prevention directly supports quality outcomes, enhances reimbursement, and improves patient trust. By managing denials strategically, hospitals turn a traditional operational challenge into an opportunity for growth and leadership in value-based care.

Bottom Line

Star Ratings matter because they connect quality, perception, and financial outcomes. To improve them, hospitals must ensure that clinical data accurately reflects the care provided, a process rooted in documentation and coding. Denials are not only a financial burden but also a quality risk; hospitals that fail to address denial management jeopardize both their bottom line and their reputation. Reducing denials is a win-win strategy that protects revenue, ensures fair representation of outcomes, and strengthens a hospital’s reputation through improved Star Ratings.

Leah Jeffries, RHIT, CDIP, CCS, CCS-P

Managing Consultant, Strategy at UASI

Centers for Medicare & Medicaid Services. (2024). Overall hospital quality star rating.
Available at https://data.cms.gov/provider-data/topics/hospitals/overall-hospital-quality-star-rating/

Centers for Medicare & Medicaid Services. (2025). Transforming Episode Accountability Model (TEAM).
Available at https://www.cms.gov/priorities/innovation/innovation-models/team-model

Centers for Medicare & Medicaid Services. (2024). Hospital quality star ratings methodology.
Available at https://qualitynet.cms.gov/inpatient/measures/hospital-star-ratings

American Hospital Association. (2025). Denials management in hospitals.
Available at https://www.aha.org/

American College of Surgeons. (2025). Preparing for TEAM: Transforming Episode Accountability Model.
Available at https://www.facs.org/

HIV Coding Overhaul: What Coders Need to Know for FY 2026

Tue, 09 Sep 2025 18:48:40 GMT

HIV Coding Changes for FY 2026: What Coders Need to Know

Overview of FY 2026 ICD-10-CM Coding Guideline Updates

With CMS’s push towards greater clinical granularity and documentation specificity, the FY 2026 ICD-10-CM Coding Guidelines, which go into effect October 1, 2025, introduces over 487 new diagnosis codes, revises 38, and deletes 28 codes. This is nearly doubling the volume of new codes over FY 2025.

Changes to HIV Coding Guidelines in Section I.C.1.a.2

One of those major changes involves how coders select and sequence human immunodeficiency virus (HIV) codes. These changes to the guidelines, in section I.C.1.a.2, include various scenarios involving patients before, during, and after an HIV diagnosis.

I.C.1.a.2(a) tells you to assign B20 Human immunodeficiency virus [HIV] disease when physician documentation indicates the patient has acquired immunodeficiency syndrome (AIDS), HIV, “or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from the patient’s HIV positive status.”

I.C.1.a.2(c) adds clariﬁcation that you can assign B20 as a secondary diagnosis for patients with HIV who have been admitted “for an unrelated condition (such as a traumatic injury).” Per the guideline revision, the same is now going to be true for “other documented conditions.”

I.C.1.a.2(e) clarifies use of Z21 Asymptomatic human immunodeﬁciency virus [HIV] infection status. You are told to apply the code when, “‘HIV positive,’ ‘HIV test positive,’ or similar terminology is documented, and there is no documentation of symptoms or HIV-related illness.”

I.C.1.a.2(f) still tells you to assign R75 Inconclusive laboratory evidence of human immunodeﬁciency virus [HIV] for patients with inconclusive serology of HIV; however, the language “but no deﬁnitive diagnosis or manifestations of the illness” has been deleted. Patients previously diagnosed with HIV continue to assign B20, but now the diagnosis will have to be documented and not “previously known,” per guideline revision.

I.C.1.a.2(h) tells you to assign O98.7 Human immunodeﬁciency virus [HIV] disease complicating pregnancy, childbirth and the puerperium only “when a patient presents during pregnancy, childbirth or the puerperium with documented symptomatic HIV disease or an HIV related illness.” Also assign Z21 for pregnant patients, patients giving birth, and for patients during the puerperium who are either HIV-positive or who have documented asymptomatic HIV.

I.C.1.a.2(i), the language changes from “If a patient is being seen to determine his/her HIV status,” to “If a patient without signs or symptoms is tested for HIV.” Additionally, for patients with signs and symptoms presenting for testing, you are now told not to report Z11.4 Encounter for screening for human immunodeﬁciency virus [HIV].

I.C.1.a.2(j) provides revised instructions for reporting HIV-positive patients who are being treated with an antiretroviral medication. In FY 2026, assign Z21 “in the absence of any additional documentation of HIV disease, HIV-related illness or AIDS.”

Practical Documentation and Coding Considerations

Documentation specificity is critical
Look for exact terms (“HIV positive,” “AIDS,” “HIV disease,” “asymptomatic HIV”). Query if unclear.
Sequence by admission reason   
HIV-related = B20 as principal.
Unrelated dx = that condition is principal and B20 secondary.
Never revert from B20
Once HIV-related illness is documented, always use B20 on future encounters.
Apply pregnancy rules
Use O98.7 first, then B20 or Z21 based on symptoms/illness.
Add management/prevention codes
Use Z79.899 for antiretrovirals
Z29.81 for PrEP (pre-exposure prophylaxis); any risk factors should also be coded.

Tracy Blevins, MSHIM, RHIA

Senior Consultant, Audit at UASI

Works Cited

Centers for Medicare & Medicaid Services . (2025). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026.
Available at https://www.cms.gov/files/document/fy-2026-icd-10-cm-coding-guidelines.pdf

American Academy of Professional Coders . (2025, June 16). Coding update: FY 2026 ICD-10-CM official guidelines released. Available at https://www.aapc.com

CDI TIP: Neuro Storm

Sun, 07 Sep 2025 19:30:14 GMT

Neurostorming (Paroxysmal Sympathetic Hyperactivity): Documentation and Coding Guidance

What Does “Neurostorming” Mean in Clinical Documentation?

“Neuro storm” and other similar terms such as autonomic storms, hypothalamic dysregulation syndrome and sympathetic storms all equate to the condition paroxysmal sympathetic hyperactivity (PSH).
This syndrome was formally named in 2014 by an international panel looking at preferred nomenclature, definition and diagnostic criteria.
PSH is defined as a disorder in the regulation of autonomic function most observed in patients with acute brain injury, most notably severe traumatic brain injury.

Risk Factors Associated With Paroxysmal Sympathetic Hyperactivity

Traumatic brain injury (TBI)
Hypoxic ischemic injury

Clinical Indicators of Paroxysmal Sympathetic Hyperactivity

Sinus tachycardia
Elevated systolic blood pressure
Tachypnea associated with respiratory alkalosis
Diaphoresis that can progress to dehydration
Hyperthermia in some cases
Severe cases may have dystonic posturing

Treatment Approaches Documented for PSH

Reducing stimulation
Managing hyperthermia and hyperventilation
Medications
IV Morphine
Gabapentin
Beta blockers
Baclofen
Precedex infusion
Dantrolene

Coding and CDI Considerations for Neurostorming Documentation

The ICD-10-CM condition code most appropriate for reporting of PSH is G90.89, Other disorders of autonomic nervous system. There is no specific code to identify neurostorm or PSH. There are also no instructional notes for the code G90.89.

Per the ICD10-CM Official Coding Guidelines, “ If a main term cannot be located, consider a synonym, an eponym, or another alternative term. Once the main term is located, search for subterms, notes, or cross-references. Subterms provide many types of more specific information and must be checked carefully, following all the rules of alphabetization. The main term code entry should not be assigned until all subterm possibilities have been exhausted. During this process, it may be necessary to refer again to the medical record to determine whether any additional information is available to permit assignment of a more specific code. If a subterm cannot be located, the nonessential modifiers following the main term should be reviewed to see whether the subterm may be included there. If not, alternative terms should be considered”

Current coding advice notes that when the index is confusing, leading to an inappropriate code, further research is needed when the title of the code suggested by the index clearly does not identify the condition correctly.

Regarding the CDI professional, it is allowable to report code G90.89, Other disorders of autonomic nervous system in the instance where “neurostorm” is documented by the provider. A query would not be needed for clarification.

Alyce Reavis, RN, MSN, CCDS, CCS

Senior CDI Educator, Consulting Services at UASI

Works Cited

American Hospital Association. (2025). Paroxysmal sympathetic hyperactivity (neurostorming). Coding Clinic for ICD-10-CM/PCS, Second Quarter, 4.

Centers for Medicare & Medicaid Services. (2025). ICD-10-CM Official Guidelines for Coding and Reporting.
Available at https://www.cms.gov/medicare/coding/icd10

Rabinstein, A. (2024). Paroxysmal sympathetic hyperactivity. UpToDate.
Available at https://www.uptodate.com/contents/paroxysmal-sympathetic-hyperactivity

Kerecis Intact Fish Skin Grafts

Fri, 05 Sep 2025 17:22:01 GMT

Kerecis Intact Fish Skin Grafts: Documentation and Coding Considerations

Overview of Kerecis Intact Fish Skin Grafts

Kerecis, is the company pioneering the use of sustainably sourced fish skin in cellular therapy and tissue regeneration. In total, nearly 200 million people in the United States are now covered under commercial insurance plans that recognize fish skin grafts as medically necessary for chronic wound care.

Clinical Use of Fish Skin Grafts in Tissue Regeneration

According to the Kerecis website, this graft “promotes healing with minimal impairment of functionality and positive cosmetic outcomes. The product is homologous to human skin and when applied to damaged tissue such as burns or wounds, helps top support the body’s own cells to regenerate tissue.”

Coding Clinic has released official guidance regarding Kerecis graft application in the fourth quarter of 2024. Their guidance tells us to report this application as replacement of skin with nonautologous tissue, full thickness, external approach. ( ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2024 Page: 65)

CMS Coverage and Diagnosis Reporting Requirements

CMS has released an LCD regarding the covered diagnosis for this unique skin regeneration. This procedure requires a dual diagnosis requirement. When reporting E08.621, E09.621, E10.621, E11.621, E13.621, one of the following must be reported with it to identify the site and severity of the ulcer : L97.411, L97.412, L97.415, L97.416, L97.421, L97.422, L97.511, L97.512, L97.515, L97.516, L97.521, L97.522, L97.525, or L97.526.

Liz Burson, BS, CCS

Senior Consultant, Audit at UASI

Works Cited:

American Hospital Association. (2024). ICD-10-CM/PCS Coding Clinic, Fourth Quarter, 65.

Centers for Medicare & Medicaid Services. (n.d.). Local Coverage Determination (LCD): Skin substitute grafts/cellular and tissue-based products for the treatment of diabetic foot ulcers and venous leg ulcers (L36377).
Available at https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=36377

Centers for Medicare & Medicaid Services. (n.d.). Billing and coding: Skin substitute grafts/cellular and tissue-based products for the treatment of diabetic foot ulcers and venous leg ulcers (A57680).
Available at https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57680

Kerecis. (n.d.). Intact fish skin for tissue regeneration.
Available at https://www.kerecis.com

Hypoglossal Nerve Stimulant

Thu, 04 Sep 2025 13:08:12 GMT

Coding and Documentation for Hypoglossal Nerve Stimulation Procedures

Hypoglossal Nerve Stimulant placement is mainly used to treat obstructive sleep apnea.

This is a surgically implanted device that stimulates the nerves that move the tongue and open the airway while a person sleeps. This device is recommended when a CPAP device is not tolerable. As of 2023, the only hypoglossal nerve stimulator that is approved by the Food and Drug Administration is the Inspire device.

Components of a Hypoglossal Nerve Stimulation System

Breathing monitor, Pulse generator, Electrode(s), Hand-held remote control

Inspire Device Models and System Differences

*Inspire IV: three implantable components – the Inspire device, a stimulation lead and a respiratory sensing lead

*Inspire V: (newer version) eliminates the separate respiratory sensing lead, resulting in a simpler two-component system.

Covered by most insurances, however commercial insurances may only cover the procedure for people with BMI of 32 or less.

Coverage and Diagnosis Requirements

G47.33 Obstructive Sleep Apnea (adult)(pediatric)
BMI code (Z68.1-Z68.34)

CPT Coding for Hypoglossal Nerve Stimulator Procedures

64582 – Implant Inspire IV or 64568 – Implant Inspire V
64583 – Revision/Replacement of breathing & nerve stimulator electrodes
64584 – Removal of device (electrodes & generator)
61885 - Revisions from Inspire IV to Inspire V
61886 - Generator replacement with connection to 2 or more electrodes

* Append modifier 52 in instances where only a portion of the device listed in the description is revised/removed (e.g., revision of breathing sensor lead only or revision of stimulation lead only)

Practical Application

Confirm payer coverage, especially BMI limits for commercial plans.
Review the operative note to determine if the full device or only a component was revised (use modifier 52 if partial).
Select the correct CPT based on Inspire model (IV vs. V).
For Medicare, always include both OSA and BMI codes.

Katie Brown, CCS

Senior Consultant, Audit at UASI

Works Cited

Karen Zupko & Associates, Inc. (2025, August 14). Coding for Inspire. Available at https://www.kzanow.com/coding-coaches/coding-for-inspire-8-14-25

Johns Hopkins Medicine. (n.d.). Hypoglossal nerve stimulation implant for sleep apnea. Available at https://www.hopkinsmedicine.org/health/conditions-and-diseases/obstructive-sleep-apnea/hypoglossal-nerve-stimulation

Key FY 2026 ICD-10-CM Updates

Tue, 26 Aug 2025 16:27:39 GMT

Key FY 2026 ICD-10-CM Updates That Will Influence Coding Accuracy and Reporting

What’s Changing in the FY 2026 ICD-10-CM Update

CMS has released the FY 2026 ICD-10-CM October 1st updates ushering in the annual set of updates to diagnosis codes used across all care settings. While there are hundreds of changes, a handful are expected to have an outsized effect on reimbursement, case mix index, quality reporting, and value-based payment programs. Below are the most consequential areas and how organizations should prepare.

Expanded SDOH Coding and Why It Matters for Reporting

CMS continues to increase the clinical and financial importance of Z-codes representing social determinants of health. FY 2026 includes additional granularity under Z59 (Problems related to housing and economic circumstances) and Z63 (Other problems related to primary support group) . These updates enable coders to capture detailed scenarios such as unstable housing, caregiver burnout, or financial stress.

Why it matters: Risk-adjusted reimbursement methodologies increasingly incorporate SDOH information. Capturing these factors can raise expected resource utilization and affect payment under ACO models, Medicare Advantage plans, state Medicaid programs, and commercial risk contracts.

New Cardiac and Vascular Coding Specificity for FY 2026

New codes and revised definitions impact common high-dollar cardiac conditions. FY 2026 introduces greater specificity for acute myocardial infarction (AMI) types, multiple new codes distinguishing heart failure phenotypes such as HFpEF and HFrEF , and classifications for cardiorenal syndrome subtypes .

Reimbursement impact: More granular codes will drive improved CC/MCC assignment and DRG differentiation. Coders must document ejection fraction, duration of symptoms, and any associated kidney injury to select the most appropriate codes and capture full acuity.

Behavioral Health Diagnostic Refinements in the FY 2026 Update, Section I.C.5

Behavioral health continues to grow as a coding priority. The FY 2026 update expands the F32-F33 (Major depressive disorder) series with added symptom severity and episode descriptors. Coding updates also refine substance use disorder remission statuses and broaden anxiety disorder codes , such as panic disorder and generalized anxiety in adults.

Reimbursement impact: Psychiatric service reimbursement relies heavily on precise coding. Capturing episode specifics can support appropriate payment, authorization management, and stratification in behavioral health value-based programs.

Obstetric and Neonatal Coding Changes to Watch, Sections I.C.15 and I.C.16

Updates include optional “context” codes under O09 High-risk pregnancy supervision to capture additional risk elements (advanced maternal age, assisted reproductive techniques, history of infertility). Neonatal codes such as P07 Categories for preterm infants and birth weight have been refined to reflect narrower birth-weight bands.

Reimbursement impact: These codes affect DRG placement, level-of-care coding, and newborn per-diem calculations. Accurate documentation supports proper assignment of resources for obstetric and neonatal care services.

Practical Considerations for Coding and Clinical Teams

To mitigate financial and operational impact, coding and CDI leaders should begin working now to:

Prioritize specialty-specific training beginning with high-volume areas such as cardiology, OB, behavioral health, and general medicine
Update CDI templates and provider queries with new prompts (e.g., homelessness vs housing insecurity, cardiomyopathy subtype, depressive episode severity, SDOH screening results)
Develop quick-reference “pocket guides” and cheat sheets for coders to use during the first 90 days post-go-live
Test code assignment in real sample cases now to identify documentation gaps and support provider education

Prepare Coders for a Smooth FY 2026 Transition

FY 2026 code changes go into effect for dates of service on October 1, 2025 , leaving limited time for organizations to educate coders, CDI specialists, and providers before the fiscal year begins. Structured, role-based education is critical to protecting revenue integrity and ensuring teams are prepared to absorb added specificity without disrupting workflow.

To safeguard financial performance, hospitals and health systems should:

Launch targeted micro-learning by service line tied to high-impact clinical areas
Begin dual-coding practice in the first half of CY 2025 to identify documentation gaps early
Roll out concise CDI and provider training sessions tailored to new documentation requirements

How Education Supports Accurate Coding and Reporting

Ensure accurate MS-DRG assignment and appropriate reimbursement
Capture severity and risk to support CMI and value-based payments
Reduce denials and revenue loss through stronger documentation and coding
Improve audit readiness and compliance with current CMS guidance

Kathy DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA

Manager, Coding Audit & Education at UASI

Works Cited & Additional Coding Resources

Centers for Medicare & Medicaid Services. (2025). FY 2026 ICD-10-CM official guidelines for coding and reporting (effective October 1, 2025). Available at: https://www.cms.gov/files/document/fy-2026-icd-10-cm-coding-guidelines.pdf

Centers for Medicare & Medicaid Services. (2025). ICD-10-CM diagnosis code files and resources. Available at https://www.cms.gov/medicare/coding-billing/icd-10-codes

New Technology: The FFX®System

Mon, 25 Aug 2025 14:28:59 GMT

New Technology Coding: The FFX® Lumbar Facet Fixation System

Overview of the FFX Lumbar Facet Fixation System

Since the introduction of ICD-10, spinal fusions have been a topic among coders and auditors. When coding spinal fusions, we typically look for where the instrumentation was placed: pedicles (posterior column) or disc space (anterior column). New technology has been created to treat lumbar spinal stenosis and facet syndrome. This new technology is the Facet FIXation device (FFX). “The FFX®system, placed bilaterally through a posterior surgical approach and spanning and compressing the facet joint interspace, is designed to aid lumbar fusion through bilateral immobilization of the facet joints”.

Since this device is not placed in the traditional spinal column locations, ICD-10-PCS does not currently have an accurate or complete PCS code for this type of fusion. Therefore, a new technology code was introduced for this procedure.

Coding Clinic Guidance for FFX Procedures

In Coding Clinic fourth quarter 2024 pg 49, we are instructed to create a code from the XRG fusion of joints table, with a device value of E “facet joint fusion device, paired titanium cages” with the qualifier of A to indicate that this is new technology, group 10.

Kendra Adams, RHIT

Senior Consultant, Audit at UASI

Works Cited

SPINEMarketGroup. (2022). FFX lumbar facet fixation. Available at https://thespinemarketgroup.com/ffx-lumbar-facet-fixation/

American Hospital Association. (2024). Fixation of lumbar facet joint. ICD-10-CM/PCS Coding Clinic, Fourth Quarter, 49.
Effective with discharges October 1, 2024. Available at https://www.findacode.com/newsletters/aha-coding-clinic/icd/fixation-lumbar-facet-joint-I114051.html

Transforming Clinical Documentation Improvement Programs

Wed, 20 Aug 2025 18:28:43 GMT

Rethinking Clinical Documentation Improvement: Why Accuracy Matters More Than Metrics

For years, many Clinical Documentation Integrity (CDI) programs have focused heavily on financial metrics like DRG maximization, CC/MCC capture, and CMI shifts. While these numbers can be helpful for spotting trends, benchmarking, and understanding patient populations, they shouldn’t be the sole measure of success. When programs lean too much on these metrics, they risk stalling progress, losing physician engagement, and limiting long-term impact creating a band aid over the larger underlying issues. A stronger, more lasting approach puts clinical accuracy, provider education, and telling the complete patient story at the center, with financial results following naturally from doing the right work.

Learn more about how CDI programs support accurate clinical documentation.

Where Traditional CDI Models Fall Short

In a traditional CDI setup, much of the work happens after the fact. Queries go out once documentation is already complete, and success is judged by things like query volume, response rates, and short-term revenue gains. While this can boost the bottom-line short term the moment, it rarely fixes the real documentation gaps. For physicians, this approach often feels like an added layer of administrative work that interrupts their day and adds to compliance fatigue.

Despite agreement among many CDI leaders that the focus needs to shift toward clinical understanding and root cause analysis of documentation and quality issues, the revenue-first model still dominates. Financial leaders often focus on revenue KPIs to gauge program performance, but these numbers tell only part of the story. While CDI must ultimately be financially viable, lasting success also depends on accurate reporting, quality outcomes, and better coordination of care.

CDI 2.0 and the Shift Toward Clinical Clarity

The CDI 2.0 model focuses on clinical clarity, medical necessity, and improved communication across the care continuum. It blends clear, concise documentation into daily workflows and makes education for providers an ongoing priority formed from partnership with the CDI team. By working this way, documentation is improved at the source rather than adjusted after the fact.

When CDI is positioned as a partner in improving patient care, physicians tend to see it as support rather than oversight. The result is documentation that paints a truer picture of the patient’s condition, which improves quality reporting, revenue integrity, patient safety, and collaboration across the care team.

Why Clinical Accuracy Is the Foundation of Sustainable CDI

Organizations that embrace a clinically driven CDI model not only see stronger physician engagement but also achieve more lasting improvements in documentation. This connection is reflected in ACDIS’s Measuring and Valuing Quality survey, where nearly 60% of CDI professionals reported prioritizing Severity of Illness and Risk of Mortality measures ahead of purely financial outcomes. Similarly, the Optimized Comprehensive CDI Programs report found that 73% of respondents identified physician engagement and retention of education as key indicators of success, underscoring that sustainable CDI programs are built on clinical accuracy and provider partnership rather than short-term financial gains.

This emphasis on clinical accuracy also extends to quality reporting. The ACDIS CDI and Quality Improvement survey showed that CDI teams track Present on Admission indicators (88%), Patient Safety Indicators (78%), and Hospital-Acquired Conditions (77%), highlighting how documentation accuracy supports organizational quality goals.

Lastly, a recent exploratory analysis published in Health Services Research found that hospitals performing better on quality measures such as lower readmission rates, fewer complications, and higher patient satisfaction also tended to report stronger financial results (Carey and Burgess 2023). When CDI programs prioritize accuracy and completeness in the medical record, they not only strengthen clinical quality measures but also support long-term financial stability.

How Accurate Documentation Supports Better Outcomes

As the healthcare landscape continues to evolve, CDI programs that focus on clinical accuracy will be best positioned to adapt and grow. When provider education, quality reporting, and financial performance are aligned around the complete patient story, CDI becomes more than a safeguard for revenue, it becomes a meaningful driver of better care. The future of CDI depends on programs that build physician trust, improve outcomes, and achieve financial stability as the natural result of accurate documentation.

Rachel Mack, MSN, RN, CCDS, CDIP, CCS, CRC

Managing Consultant, CDI at UASI

Works Cited

Association of Clinical Documentation Integrity Specialists. (2021). Measuring and Valuing Quality. Available at: acdis.org/resources/measuring-and-valuing-quality

Association of Clinical Documentation Integrity Specialists. (2023). Optimized Comprehensive CDI Programs. Available at: acdis.org/resources/acdis-council-report-optimized-comprehensive-cdi-programs

Association of Clinical Documentation Integrity Specialists. (2023). CDI and Quality Improvement. Available at: acdis.org/resources/acdis-council-report-cdi-and-quality-improvement

Carey, K., & Burgess, J. (2023). An exploratory analysis of the association between hospital quality measures and financial performance. Health Services Research, 58(6), 1242–1252. Available at: pmc.ncbi.nlm.nih.gov/articles/PMC10606508

Hypertensive Emergency

Mon, 11 Aug 2025 16:28:28 GMT

Hypertensive Emergency: ICD-10-CM FY 2025 Sequencing and Coding Guidance

What Is a Hypertensive Emergency?

Hypertensive Emergency is a severe increase in high blood pressure (typically greater than 180 systolic/120 diastolic) with potentially life-threatening symptoms or damage to vital organs.

**In FY 2025, new sequencing instructions were added to ICD-10 for hypertensive emergency.**

The Tabular List “Use Additional code” instructional note for hypertensive emergency must be followed when supported in documentation, which includes CDI query responses.  Hypertensive emergency I16.1 is appropriately sequenced as Principal Dx if an associated organ dysfunction / manifestation is documented.

Documentation and Cause-and-Effect Considerations

Cause-Effect documentation may be in one concise statement or   within the context of several narrative statements indicating CVA, CHF exacerbation, etc. is a manifestation of hypertensive emergency.

{ Code also any identified hypertensive disease ( I10 - I15 , I1A ) as instructed by ICD-10 tabular}.

Katie Brown, CCS

Senior Consultant, Audit at UASI

Works Cited

BMJ Best Practice. (2025). Hypertensive emergencies: Symptoms, diagnosis, and treatment. Available at:
https://bestpractice.bmj.com/topics/en-us/27

Centers for Disease Control and Prevention. (2025). ICD-10-CM Tabular List of Diseases and Injuries. Available at:
https://www.cdc.gov/nchs/icd/icd-10-cm/index.html

New ICD-10-CM Code E11.A: Type II diabetes mellitus without complications in remission

Thu, 07 Aug 2025 15:52:53 GMT

New ICD-10-CM Code E11.A: Type 2 Diabetes Mellitus Without Complications in Remission

Background and FY 2026 Update

With the 2026 IPPS Proposed Final Rule comes a new diabetes code, E11.A, Type II diabetes mellitus without complications in remission. This is a non-CC/MCC and is assigned to MDC 10.

ICD-10-CM Official Coding Guidance for E11.A

Section I.C.4.a.1.(b) - “Code E11.A, Type 2 diabetes mellitus without complications in remission, is assigned based on provider documentation that the diabetes mellitus is in remission. If the documentation is unclear as to whether the Type 2 diabetes mellitus has achieved remission, the provider should be queried. For example, the term “resolved” is not synonymous with remission.”

Clinical Criteria for Diabetes Mellitus in Remission

Note* - Remission does not mean cure. Ongoing monitoring is essential as relapse is possible.

1. Prior Diagnosis of Diabetes Mellitus

Documented history of type 2 diabetes mellitus, diagnosed using standard criteria:
HbA1c ≥ 6.5%
Fasting plasma glucose ≥ 126 mg/dL
2-hour plasma glucose ≥ 200 mg/dL during an OGTT
Random plasma glucose ≥ 200 mg/dL with classic symptoms

2. Normal or Controlled Glucose Levels Without Medications

The patient is not taking any antidiabetic medications (oral agents, insulin, or non-insulin injectables).
Glycemic control is sustained through lifestyle modifications, such as diet and exercise.
HbA1c < 6.5%, and sometimes < 6.0%, on two occasions at least 6 months apart without pharmacologic therapy.

3. Duration of Remission

Partial remission: HbA1c < 6.5% and fasting glucose 100–125 mg/dL for at least 1 year without medications.
Complete remission: HbA1c in the normal range (<5.7%) and fasting glucose <100 mg/dL for at least 1 year.
Prolonged remission: Complete remission lasting ≥5 years.

4. Documentation Must Include

Clear statement that diabetes is in remission or resolution.
No current use of diabetes medications.
Current HbA1c values.
Lifestyle interventions being used.
Absence of ongoing diabetic complications (or if present, they are noted as sequelae)

5. What about Type I diabetes? Is remission associated?

“Honeymoon Phase” vs. Remission
Some individuals newly diagnosed with type 1 diabetes may experience a "honeymoon phase":
This is a temporary period (weeks to months) where insulin needs to decrease and blood glucose levels may normalize.
However, this is not true remission, as the autoimmune process continues and insulin dependence eventually returns.

Clinical Scenario

Dr. Doctor,

Documentation in your visit note indicates the patient has a documented history of type 2 diabetes mellitus, but current labs show:

HbA1c: 5.6%
No diabetes medications (e.g., insulin, metformin) currently prescribed
Patient reports lifestyle changes (e.g., diet and weight loss)
No hyperglycemia documented during this admission or recent visits

Query

Based on the clinical picture, can you please clarify the patient’s current diabetic status?

☐ Type 2 diabetes mellitus – continue to document and treat as active

☐ History of type 2 diabetes mellitus, currently in remission (no medications, normal glucose values)

☐ Other: ________________

Jessica Lutz, MBA, RHIA, CCS
AHIMA Microcredential: Auditing: Inpatient Coding

Senior Consultant, Audit at UASI

Works Cited:

American Diabetes Association. (2024). Standards of care in diabetes—2024. Available at:
https://professional.diabetes.org/standards-of-care

American Diabetes Association. (2024). Glycemic goals and hypoglycemia. Available at:
https://diabetesjournals.org/care/article/47/Supplement_1/S111/153951/6-Glycemic-Goals-and-Hypoglycemia-Standards-of

Buse, J. B., et al. (2009). How do we define cure of diabetes? Available at:
https://pubmed.ncbi.nlm.nih.gov/19875608/

Centers for Medicare & Medicaid Services. (2026). ICD-10-CM Official Guidelines for Coding and Reporting. Available at:
https://www.cms.gov

Centers for Medicare & Medicaid Services. (2026). Inpatient prospective payment system (IPPS) proposed rule. Available at:
https://www.cms.gov

CMS Releases Multiple FY 2026 Payment Updates

Wed, 06 Aug 2025 17:10:42 GMT

CMS Releases Multiple FY 2026 Payment Updates: Key Takeaways for Providers

Yesterday, the Centers for Medicare & Medicaid Services released several final rules and updates impacting payment and quality expectations for FY 2026. Below is a summary of each announcement and its likely effect on providers across care settings.

Quarterly Listing of CMS Program Issuances (April–June 2025)

This listing compiles all CMS transmittals, memoranda, manual updates, and other instructions issued in the second quarter of 2025. While not tied to a specific payment update, it sets the compliance and operational agenda that contractors and providers need to follow going into the next fiscal year.

Impact: Compliance leaders and revenue cycle teams should review the quarterly listing closely to ensure internal processes reflect the latest guidance on claims processing, provider enrollment, coverage determinations, and survey protocols.

Announcement available at: https://www.federalregister.gov/documents/2025/08/05/2025-14822/medicare-and-medicaid-programs-quarterly-listing-of-program-issuances-april-through-june-2025

FY 2026 Hospice Wage Index and Payment Rate Update + Hospice Quality Reporting Program (HQRP) Changes

CMS finalized a payment rate increase for hospices along with routine wage index updates. Revisions to HQRP continue the move toward outcome-oriented quality measurement, including preparation for the upcoming HOPE assessment tool.

Impact: Hospices should expect modest payment growth coupled with expanded quality reporting expectations that will require stronger documentation and care coordination practices.

Announcement available at: https://www.federalregister.gov/documents/2025/08/05/2025-14782/medicare-program-fy-2026-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting

FY 2026 Inpatient Psychiatric Facility (IPF) PPS Final Rule

This rule updates the IPF per diem base rate, wage index, and labor share for FY 2026. CMS also modifies several measures in the IPF Quality Reporting Program to put greater emphasis on behavioral health outcomes and performance improvement.

Impact: Psychiatric hospitals and units will see a net payment increase, but must be ready to support enhanced quality tracking and accurate measure reporting to avoid penalties.

Announcement available at: https://www.federalregister.gov/documents/2025/08/05/2025-14781/medicare-program-fy-2026-inpatient-psychiatric-facilities-prospective-payment-system-rate-update

FY 2026 Inpatient Rehabilitation Facility (IRF) PPS Final Rule

IRFs will receive a payment increase in FY 2026 tied to market basket and wage index changes. CMS also continues to strengthen the IRF Quality Reporting Program by refining functional outcome measures and signaling future alignment with post-acute value initiatives.

Impact: IRFs should prepare for higher reimbursement alongside increased accountability for quality outcomes and performance on patient assessment data.

Announcement available at: https://www.federalregister.gov/documents/2025/08/05/2025-14780/medicare-program-inpatient-rehabilitation-facility-prospective-payment-system-for-federal-fiscal

Bottom Line for Providers

CMS continues its trend of linking payment updates to quality, transparency, and data integrity. While most settings will enjoy FY 2026 reimbursement increases, each sector should be bracing for greater reporting rigor and operational alignment with value-based objectives.

To stay ahead, providers should prioritize internal assessments of their current documentation, coding, and quality reporting workflows to identify any vulnerabilities, considering the new requirements. Investment in education, technology, and cross-functional collaboration will be essential to safeguard compliance, protect revenue, and successfully navigate the evolving value-based landscape.

CMS Issues Advisory: Qualified APM Participants Must Submit Taxpayer ID and Quality Data by September 1 to Receive 2025 Incentive Payments

katie.curry@uasisolutions.com (Katie Curry) — Wed, 30 Jul 2025 13:08:52 GMT

CMS Advisory: Action Required to Receive 2025 APM Incentive Payments

CMS Advisory Overview

The Centers for Medicare & Medicaid Services (CMS) has released an important advisory notifying certain clinicians who qualified as Alternative Payment Model (APM) participants that they must take immediate action to receive their 2025 incentive payments.

Affected APM Participants

CMS has identified a group of qualifying APM participants (QPs) from the 2023 performance year whose taxpayer identification numbers (TINs) are either missing or unidentifiable. As a result, CMS is currently unable to disburse the 3.5% APM incentive payments owed for the 2025 payment year.

Action Required by September 1, 2025

To avoid forfeiting their incentive payments, affected QPs must:

Submit their current Medicare billing information, including TINs, using the instructions provided in a separate notification from CMS.
Ensure all relevant Quality Payment Program (QPP) data from the 2023 clinical performance period is submitted by September 1, 2025.

Failure to provide the required information by the deadline will result in forfeiture of the APM incentive payment for the 2023 performance year.

CMS has made a list of impacted QPs available and is urging all clinicians who expected to receive an APM incentive payment but have not yet received it to verify their status and submit the necessary documentation.

Processing Timeline

CMS will begin processing all timely submissions after the September 1 deadline. The validation and verification process may take up to three months before payments are issued.

HIM leaders should take note because missed incentive payments can result in a significant loss of expected revenue, potentially up to 3.5% per qualifying clinician . Ensuring timely submission of TINs and quality data helps protect the organization’s reimbursement and supports compliance with value-based care initiatives. Proactively coordinating with clinicians and billing teams now can prevent revenue disruptions and strengthen your organization's performance under future APM reporting cycles.

For questions, providers can contact the QPP Help Desk at 1-866-288-8292.

The complete notice is available here at the Federal Register: https://www.federalregister.gov/documents/2025/07/30/2025-14434/medicare-program-alternative-payment-model-apm-incentive-payment-advisory-for-clinicians-request-for

Coding Accuracy in a Value-Based World & Why It’s No Longer Just About the Right DRG

katie.curry@uasisolutions.com (Katie Curry) — Wed, 23 Jul 2025 14:41:12 GMT

From DRG Assignment to Strategic Impact: Coding Accuracy in a Value-Based Care Environment

Summary of Presentation by Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA – July 14, 2025

Hospitals can no longer focus exclusively on assigning the correct MS-DRG as value-based care (VBC) demands a more comprehensive approach that centers on complete, specific, and accurate documentation and coding. Reimbursement, quality rankings, and publicly reported outcomes now rely on data integrity at the patient level.

The Shift to Value-Based Care

Value-based care prioritizes quality over quantity. Payment models reward outcomes, care coordination, and patient experience rather than volume of services, and this transformation is reshaping inpatient payment strategies. According to CMS, over 90% of Medicare Advantage enrollees are now in plans that include some form of value-based payment model (CMS, 2023). Programs such as the Hospital Value-Based Purchasing (VBP) program adjust hospital reimbursement based on performance in key domains: mortality, safety, patient experience, and efficiency.

Under the VBP program, CMS withholds 2% of base DRG payments and redistributes those funds based on performance scores (CMS VBP, 2024). Hospitals that perform well receive a net increase in payments and those that underperform lose a portion of their DRG reimbursement. These performance scores also feed into the CMS Star Ratings, impacting public perception, competitive standing, and contract negotiations with commercial payers.

The Role of Accurate Coding in Value-Based Models

Coding accuracy is foundational to success in value-based models. Accurate codes support appropriate reimbursement, enable risk adjustment, and fuel quality improvement efforts. They also ensure complete and defensible clinical documentation. Inaccurate or incomplete coding can exclude key diagnoses from risk models, skewing expected outcomes and exposing hospitals to financial penalties or public underperformance.

Understanding Risk Adjustment and Quality Measures

Risk adjustment allows payers to compare patient outcomes across hospitals fairly by accounting for differences in patient acuity and comorbidities. CMS uses tools such as the Elixhauser Comorbidity Index to assess 30-day mortality, readmissions, and safety events. Diagnoses must be coded correctly and tagged as Present on Admission (POA) to be included. The mortality domain under the CMS Stars program includes seven metrics and evaluates all-cause mortality within 30 days. According to CMS, more than 3,000 hospitals receive mortality scores based on risk-adjusted data derived from claims and coded diagnoses (CMS Hospital Compare, 2024).

Risk adjustment also influences private payers and rankings. U.S. News & World Report hospital rankings and Leapfrog scores incorporate risk-adjusted data derived from coded information. Missing a chronic condition like COPD, CKD, or diabetes may not impact the DRG but could dramatically alter performance scores and ranking outcomes.

CDI, Coding, and Strategic Impact

Clinical Documentation Integrity teams must prioritize specificity and relevance to risk models. This includes expanding review focus to non-mortality domains such as readmissions and complications. Coders and CDS specialists should be equipped to query not only for DRG optimization but also for clinical accuracy and data completeness.

Hospitals that invest in this strategy see results. According to the AHIMA Foundation, hospitals with strong CDI programs report an average increase in captured comorbid conditions of 25–30%, resulting in improved risk scores, quality metrics, and reimbursement (AHIMA CDI Impact Study, 2023).

Real World Medical Coding Example

Consider the following inpatient scenario:

A patient is admitted with new-onset atrial fibrillation (A-fib) that triggers acute congestive heart failure (CHF). Both conditions are evaluated, treated, and monitored during the admission. The provider documents both diagnoses clearly in the record, and clinical indicators support the acuity of each.

At the coding level, two principal diagnosis (PDX) options are clinically valid:

I48.91 (Unspecified atrial fibrillation) results in DRG 310, with a relative weight of 0.553 and a reimbursement of approximately $4,736
I50.9 (Unspecified heart failure) results in DRG 293, with a relative weight of 0.5615 and a reimbursement of approximately $4,795
Although CHF offers a slightly higher payment, it carries added risk in value-based care programs. Coding CHF as the PDX places this case in the CMS Heart Failure 30-Day Readmission Cohort, which is publicly reported and directly impacts a hospital’s readmission scores and star ratings. Coding A-fib, by contrast, avoids triggering that metric.

Key takeaway for coders : Don’t make DRG assignment decisions in isolation. Collaborate with CDI and quality teams to understand downstream implications. Even small DRG differentials may lead to long-term financial risk if they adversely impact quality metrics. Be aware of cohort inclusion criteria tied to mortality, complications, and readmissions when selecting the principal diagnosis.

When both conditions meet criteria for PDX, and documentation supports either as the focus of care, coders must weigh the immediate DRG return against long-term quality exposure. Query for specificity when it may influence cohort inclusion or risk adjustment, not just DRG grouping.

From Code Assignment to Strategic Impact

In today’s value-based care environment, coding professionals play a strategic role in shaping financial outcomes, quality performance, and public reporting. Accurate, complete, and specific coding is no longer just about selecting the highest-paying DRG. It is about capturing the full complexity of the patient’s condition, supporting risk adjustment models, and influencing quality domains that determine reimbursement, ratings, and reputation. Coders and CDI teams must operate as clinical and operational stewards, ensuring documentation supports both the clinical reality and the evolving expectations of payers and regulators. The future of hospital success depends on how precisely and thoughtfully each case is coded.

Kathy DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA

Manager, Coding Audit & Education at UASI

Kathy has 25+ years of expertise in health information management, coding, compliance, and reimbursement strategy. A nationally recognized educator and past ICD-10 content developer for AHIMA, she has supported coding education, curriculum development, and technical guidance for organizations across the country. Named one of ACDIS’s top ten CDI professionals, Kathryn is a frequent speaker and trusted advisor on CDI, coding, and HIM-related best practices.

Works Cited:

Centers for Medicare & Medicaid Services. Overall Hospital Quality Star Rating. Available at:
https://www.medicare.gov/care-compare/resources/hospital/overall-star-rating

AHIMA Foundation. (2023). CDI program impact report. Available at:
https://www.ahima.org/education-events/clinical-documentation-integrity-cdi-education/

Centers for Medicare & Medicaid Services. 2024 Medicare Advantage and Part D rate announcement. Available at:
https://www.cms.gov/newsroom/fact-sheets/fact-sheet-2024-medicare-advantage-and-part-d-rate-announcement

Agency for Healthcare Research and Quality. Elixhauser Comorbidity Index. Available at:
https://hcup-us.ahrq.gov/toolssoftware/comorbidityicd10/comorbidity_icd10.jsp

Initial vs. Subsequent Encounter

katie.curry@uasisolutions.com (Katie Curry) — Tue, 22 Jul 2025 12:55:25 GMT

Initial vs. Subsequent Encounters in ICD-10-CM: Getting the 7th Character Right

Why the 7th Character Matters in Injury Coding

Many coders still struggle with assigning the seventh character for initial and subsequent encounters. Using these correctly ensures accurate reimbursement and avoids claim denials.

Initial Encounter (7th Character “A”): Active Treatment

When assigning the 7th character for injuries or conditions like fractures, sprains, or open wounds, do not confuse “initial” with the patient’s first visit.

Initial Encounter (A) = Active treatment is still being provided – “surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.”

Subsequent Encounter (7th Character “D”): Routine Aftercare

Subsequent Encounter (D) = The patient is in the healing or recovery phase, receiving routine follow-up care - “cast change or removal, an X-ray to check healing status of fracture, removal of an external or internal fixation device, medication adjustment, and other aftercare and follow-up visits following treatment of the injury or condition.”

Key Coding Rule: Care Phase Matters More Than Care Setting

In ICD-10-CM, “initial” vs. “subsequent” is about the type of care being provided, not the location (like inpatient vs. outpatient)

Use 7th character “A” (Initial Encounter) when the patient is receiving active treatment for the injury – regardless of whether they’re in the ER, surgery, or admitted inpatient.
Use 7th character “D” (Subsequent Encounter) once the patient is receiving routine aftercare for healing – even if they are still in the hospital (e.g., rehab or post-op management).

Tracy Blevins, MSHIM, RHIA

Senior Consultant, Audit at UASI

Works Cited:

American Hospital Association. (2015). Initial and subsequent encounters for injuries. Coding Clinic for ICD-10-CM and ICD-10-PCS, First Quarter 2015, pp. 3–21.

Centers for Medicare & Medicaid Services . (2022). ICD-10-CM Official Guidelines for Coding and Reporting. U.S. Department of Health and Human Services. Available at: https://www.cms.gov

American Academy of Professional Coders . (n.d.). Resolve initial vs. subsequent encounter misconceptions. AAPC Knowledge Center. Available at: https://www.aapc.com/blog/82768-resolve-initial-vs-subsequent-encounter-misconceptions/

Optilume

katie.curry@uasisolutions.com (Katie Curry) — Mon, 21 Jul 2025 19:17:42 GMT

Optilume CPT Coding Guidance for Urethral Stricture and Stenosis

What Is Optilume?

Optilume is an FDA approved drug-coated balloon, developed by Urotronic, that is inserted via cystoscopy to dilate and treat urethral strictures or stenosis caused by benign prostatic hyperplasia (BPH). It is a minimally invasive procedure that provides immediate relief from the urinary symptoms men can experience with BPH.

A CPT code, 52284, was introduced in 2024 which can be used when a cystoscopy with Optilume is performed.

The drug on the outer surface of this balloon (paclitaxel), once absorbed, may help maintain the stricture expansion and help improve urinary flow. The balloon is not left inside the patient, but rather taken out after 5 minutes of inflation, leaving the drug to do its job with the rest.

Key Coding Considerations for Coders

Use CPT 52284 only when a drug-coated balloon (like Optilume) is used during cystoscopy to treat urethral stricture/stenosis.
Documentation must clearly state:
Use of Optilume
Paclitaxel drug delivery
Balloon inflation and removal
Do not code separately for the drug
Use C1889 for the device code
Ensure the diagnosis supports stricture/stenosis, not just BPH.
This code is new in 2024—don’t use it for earlier dates.
Watch for bundling and use modifiers only if appropriate.
Check payer policies for coverage and authorization requirements

Katie Brown, CCS

Senior Consultant, Audit at UASI

Works Cited

Food and Drug Administration. (2023). Optilume BPH catheter system (P220029). Available at:
https://www.fda.gov/medical-devices/recently-approved-devices/optilume-bph-catheter-system-p220029

Laborie Medical Technologies. (n.d.). Optilume drug-coated balloon for urethral stricture treatment. Available at:
https://www.laborie.com/product/optilume-drug-coated-balloon-for-urethral-stricture-treatment/

Urotronic, Inc. (n.d.). Optilume. Available at:
https://urotronic.com/

CMS Audit Expansion Signals Regulatory Shift for Medicare Advantage Insurers

katie.curry@uasisolutions.com (Katie Curry) — Mon, 14 Jul 2025 20:08:19 GMT

CMS Expands Medicare Advantage Audits: What the New Enforcement Push Means

CMS Announces a Major Expansion of Medicare Advantage Audits

The Centers for Medicare & Medicaid Services (CMS) has unveiled a sweeping expansion of its Medicare Advantage (MA) audit program, signaling a significant escalation in federal oversight. Under the new initiative, CMS will conduct annual audits of all 550 eligible MA contracts which is a dramatic increase from the roughly 60 plans reviewed each year in the past. Additionally, the agency has committed to clearing a year-long backlog of audits, prioritizing unresolved payment reviews from 2018 through 2024, with a completion deadline set for early 2026.

As CMS increases Medicare Advantage audit scrutiny, organizations monitoring quality measures and Patient Safety Indicators (PSIs) may need to engage structured PSI service programs to address audit exposure and reporting requirements.

Why Medicare Advantage Insurers Are Facing Heightened Scrutiny

The announcement has sent shockwaves through the healthcare industry and financial markets, triggering swift backlash from major insurers. UnitedHealth Group and Humana, two of the largest Medicare Advantage (MA) providers, are now under heightened scrutiny, with UnitedHealth facing an active U.S. Department of Justice (DOJ) investigation into potential MA billing fraud. In an effort to preempt further regulatory action, both insurers have publicly endorsed reforms aimed at curbing the use of insurer-initiated home risk assessments. A controversial practice linked to inflated Medicare reimbursements. Analysts warn that such changes could reduce Medicare spending by as much as $124 billion over the next decade, dealing a significant blow to insurers that rely on these revenue streams.

Preparing for Increased Oversight and Documentation Review

The expanded Medicare Advantage (MA) audit program marks a seismic shift in regulatory enforcement, fundamentally altering the compliance landscape for insurers and providers. Organizations must now brace for unprecedented documentation scrutiny, rigorous retrospective audits, and a far more aggressive federal oversight regime. To navigate this new reality, compliance programs require immediate reassessment, internal audit processes must be strengthened, and risk-sharing agreements should be reevaluated to mitigate the substantial financial and operational exposures stemming from this heightened oversight.

Works Cited:

Centers for Medicare & Medicaid Services. (2025). CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits. U.S. Department of Health and Human Services. Available at: https://www.cms.gov/newsroom/press-releases/cms-rolls-out-aggressive-strategy-enhance-and-accelerate-medicare-advantage-audits

Wall Street Journal / Reuters. (2025). Humana to back curbs to Medicare Advantage billing practices, WSJ reports. Reuters (citing WSJ). Available at: https://www.reuters.com/business/healthcare-pharmaceuticals/humana-back-curbs-medicare-advantage-billing-practices-wsj-reports-2025-06-05/

Neonatal Encephalopathy

katie.curry@uasisolutions.com (Katie Curry) — Wed, 09 Jul 2025 19:04:55 GMT

Neonatal Encephalopathy: Documentation and Coding Considerations for CDI

What Is Neonatal Encephalopathy?

Definition: Neonatal encephalopathy (NE) is a clinically defined syndrome of disturbed neurologic function in the earliest days of life in a term or late preterm infant, manifested by difficulty with initiating and maintaining respiration, depression of tone and reflexes, subnormal level of consciousness, and often seizures.

Common Clinical Presentation and Indicators

Clinical presentation:

Low APGAR scores and/or weak/absent cry in the delivery room.
Hyperalert, irritable, lethargic, obtunded.
Decreased spontaneous movements, poor tone, blunted or absent primitive reflexes, seizure activity.
Breathing and/or feeding difficulties.

Documentation Tips:

The CDS should review to identify the underlying etiology . (e.g., hypoxic-ischemic event, infection, metabolic disorder).
Review clinical indicators that may indicate associated conditions , such as seizures, abnormal imaging, acidosis, or multi-organ dysfunction.
Review the documentation for the timing of onset (e.g., at birth, delayed).
Common clinical indicators include low APGAR scores, need for resuscitation, abnormal tone, or altered level of consciousness.

ICD-10-CM Coding:

P91.811, Neonatal encephalopathy in diseases classified elsewhere
P91.819, Neonatal encephalopathy, unspecified
Use when the type or etiology of NE is not documented

Sample Provider Query

To the Attending Neonatologist:

Documentation in the medical record indicates the newborn infant delivered from mother with placental abruption demonstrates seizures, abnormal muscle tone, low APGAR scores, and required resuscitation at birth. Imaging showed evidence of cerebral edema. The diagnosis of “neonatal encephalopathy” was documented in the assessment.

Query:

Based on the clinical indicators, can you clarify the type and cause of the encephalopathy in this newborn?

Please select the most appropriate option below or specify another diagnosis:

Neonatal encephalopathy due to Hypoxic-ischemic encephalopathy (HIE)

Neonatal encephalopathy due to other etiology (please specify)

Other (please specify): __________

Alyce Reavis, RN,MSN,CCDS,CCS

Senior CDI Educator, Consulting Services at UASI

Works Cited:

Centers for Medicare & Medicaid Services . (2024). ICD-10-CM Official Guidelines for Coding and Reporting. U.S. Department of Health and Human Services. Available at: https://www.cms.gov

American Academy of Pediatrics . (2014). Neonatal encephalopathy and neurologic outcome, second edition. Pediatrics, 133(5), e1482–e1488.

Health Inequality Doesn’t Stop When We Advance Health Technology

katie.curry@uasisolutions.com (Katie Curry) — Tue, 01 Jul 2025 16:00:58 GMT

Clinical Documentation Integrity, AI, and Bias in Healthcare Data

Why Clinical Documentation Integrity Matters in an AI-Driven Healthcare Environment

As artificial intelligence reshapes healthcare, the accuracy and integrity of clinical data have never been more critical. At the heart of this transformation is Clinical Documentation Integrity (CDI), which is the process that ensures patient records are complete, accurate, and reflective of everyone's true clinical picture. CDI is more than a coding or compliance function; it directly influences the quality of data that drives analytics, informs patient care decisions, and feeds AI systems. Without precise documentation, AI models risk learning from flawed or incomplete narratives, which can perpetuate disparities rather than correct them.

The quality of AI-driven healthcare is only as strong as the documentation behind it. This makes CDI a foundational element in the conversation about bias, representation, and equity in healthcare data and are issues that become even more urgent as technology plays a larger role in clinical decision-making.

How Incomplete or Biased Documentation Affects AI Outcomes

Artificial intelligence is transforming healthcare, offering faster diagnostics, improved efficiency, and greater precision. However, a critical question must be addressed: What happens when the data behind these systems fails to represent the full spectrum of the population? AI systems are only as effective as the information used to train them. If that data is incomplete, biased, or skewed toward specific groups, the results will inevitably mirror and perpetuate those limitations.

In the United States, many individuals fall outside traditional definitions of what is considered "healthy." These definitions have been shaped by research that historically centers on a narrow demographic. Medical devices, for example, may perform well in clinical trials but fail to provide accurate readings for patients who do not fit the assumed norm. Pulse oximeters, for instance, have been shown to yield less accurate results for people of color. When flawed data collection tools inform AI systems, those flaws are embedded into the technology itself.

Bias in Healthcare Data and Clinical Decision-Making

Bias in medicine is not new, but AI can magnify it. Healthcare professionals, like any individual, may hold unconscious or conscious biases that affect how symptoms are interpreted, which diagnoses are considered, and how treatments are delivered. For example, attributing a patient’s symptoms primarily to their weight can result in serious conditions being overlooked. This is not anecdotal; evidence shows that larger-bodied individuals often experience delayed diagnoses and poorer outcomes due to premature dismissal of their concerns. When AI systems are trained on clinical documentation reflecting these biases, flawed reasoning becomes automated and widespread.

How Narrow Definitions of Health Shape AI Models

Definitions of health are also shaped by societal norms. The common mental image of a "healthy person" often includes someone thin, active, and young. However, this stereotype does not capture the full range of health. According to Dr. Silvana Pannain, director of Chicago Weight at the University of Chicago, individuals can be overweight yet maintain normal blood pressure, healthy cholesterol levels, and no metabolic complications. These alternative presentations of health are often overshadowed by ingrained cultural messaging, and AI, built on current practices and data, can inadvertently reinforce these narrow perceptions.

A significant source of bias in healthcare data stems from clinical research. For decades, clinical trials have primarily included Caucasian men, resulting in medications, diagnostic tools, and treatment protocols designed around a relatively uniform group. When applied to the broader population, critical differences in symptom presentation and treatment efficacy across diverse groups may be overlooked. Even among men, variations exist across racial and ethnic lines. Women, and especially women of color, remain underrepresented in the datasets used to train AI models, which can lead to misdiagnosis and inadequate care.

Why AI Requires Oversight Beyond Algorithm Design

AI is rapidly influencing many areas of healthcare, from scheduling to diagnostics and decision support. However, without deliberate oversight, these tools risk reinforcing existing disparities rather than resolving them. Developing smarter algorithms is not enough. What’s needed is the creation of smarter data practices that ensure representation from all communities, especially those historically excluded from clinical research.

Healthcare professionals must continue to serve as critical thinkers when using AI-powered tools. Technology should assist, not override, clinical judgment. Proper training is essential not just in operating AI systems, but in understanding when to question them. For example, a tool that works 95% of the time still holds a failure rate of 5%, and those failures may disproportionately affect already marginalized groups.

Why Clinical Documentation Integrity Is Central to Health Equity

Many assume that bias in healthcare has already been addressed through innovation and policy however, that assumption is incorrect. Data reflects the systems from which it is generated. Biased systems will yield biased data, and any technology built upon such data will carry forward those disparities.

As the healthcare industry advances toward AI-driven innovation, the role of Clinical Documentation Integrity must evolve in parallel. CDI professionals are uniquely positioned to advocate for inclusive, comprehensive, and precise documentation that reflects the reality of patient care across all populations. By doing so, CDI ensures that AI tools are grounded in equitable, high-quality data and therefore help to close the gap in care disparities and build a healthcare system that works for everyone.

To explore more about how data quality and representation impact healthcare outcomes, the following resources provide expert insights and current strategies:

As technology evolves, the conversation around health equity must evolve with it. Ensuring that progress benefits everyone starts with better data, better awareness, and better systems athts is largely driven by the critical work of CDI.

New Technology Alert! AVEIR™ Leadless Pacemakers

katie.curry@uasisolutions.com (Katie Curry) — Mon, 30 Jun 2025 13:12:51 GMT

Coding Dual-Chamber Leadless Pacemakers in ICD-10-PCS

Key Coding Considerations for Dual-Chamber Leadless Pacemaker Devices

Leadless pacemakers are no longer limited to single-chamber technology. Dual-chamber leadless pacemakers are now available and increasingly utilized, offering expanded pacing capabilities while maintaining the benefits of a leadless system.

From a clinical perspective, dual-chamber leadless pacemakers are designed to improve patient experience by reducing device-related complications, minimizing pocket-related infections, and eliminating lead-associated risks. These devices are also designed to be retrievable, which has contributed to broader adoption in appropriate patient populations.

Coding Considerations

When coding dual-chamber leadless pacemaker implantation procedures, several key factors must be considered.

First, dual-chamber leadless pacemakers are classified as new technology and must be coded accordingly within ICD-10-PCS. Coders should verify that the procedure meets new technology criteria as outlined in current guidance.

Second, unlike traditional single-device systems, dual-chamber leadless pacemakers involve the implantation of two separate devices , typically one placed in the right atrium and one in the right ventricle. Each device represents a distinct implantation and must be reported separately .

Accurate code assignment requires careful review of the operative report to identify:

The specific cardiac chamber for each device
The approach used for implantation
The device type and new technology designation

Coding Clinic guidance and manufacturer resources provide clarification on the appropriate ICD-10-PCS tables and code selection for dual-chamber leadless pacemaker systems. Coders should reference these materials to ensure complete and compliant reporting.

Kendra Adams, RHIT

Senior Consultant, Audit at UASI

Works Cited

American Hospital Association. (2023). ICD-10-PCS coding for leadless pacemaker systems. Coding Clinic for ICD-10-PCS, Fourth Quarter 2023, pp. 60–61.

Abbott. (2023) . AVEIR single and dual chamber leadless pacemaker systems. Abbott Laboratories. Available at: https://www.cardiovascular.abbott

Patient Safety Indicators: Aligning CDI and Coding with Quality Goals

katie.curry@uasisolutions.com (Katie Curry) — Tue, 24 Jun 2025 18:51:16 GMT

What Patient Safety Indicators Mean for CDI Coding and Quality Performance

“It’s our coders fault that we have so many PSIs!”

“The CDI specialists don’t know what to query for to get out of a PSI.”

“PSIs are too challenging to understand.”

Do these sentiments sound familiar?

For those of you working in CDI, Coding, and/or Quality, you are likely aware of the concepts behind Patient Safety Indicators (PSIs) and how they influence quality performance discussions. For those of you newer to the CDI and Coding community, let’s take a moment to break it down.

(This article focuses on educational alignment across CDI, coding, and quality, while formal PSI reporting programs support ongoing measurement, monitoring, and benchmarking.)

What Are Patient Safety Indicators (PSIs)?

PSIs are a set of measurement tools created by the Centers for Medicare & Medicaid Services (CMS) that track adverse patient outcomes. This article in particular focuses on the Inpatient space. Per the Agency for Healthcare Research and Quality (AHRQ), Patient Safety 101, “Safety” can be defined in healthcare as: “avoiding harm to patients from care that is intended to help them. It involves the prevention and mitigation of harm caused by errors of omission or commission in healthcare, and the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur.” 1

Why PSIs Matter in the Inpatient Setting

Patient safety was not at the forefront of healthcare until the late 1990’s when the Institute of Medicine (IOM) published the report, To Err is Human. This report estimated that nearly 44,000–98,000 patients die from preventable errors in American hospitals each year. 2 The body content of your post goes here. To edit this text, click on it and delete this default text and start typing your own or paste your own from a different source.

How CMS Uses PSI 90 for Performance and Payment

At present, the CMS monitors Patient Safety Indicator 90 (PSI 90), which focuses on safety-related adverse events that occur in hospitals after surgeries, procedures, and childbirth. The CMS utilizes PSI 90 to evaluate hospital performance and adjust financial reimbursements accordingly. According to CMS, “PSI 90 measure summarizes patient safety across multiple indicators, monitors performance over time, and facilitates comparative reporting and quality improvement at the hospital level.” 3

Essentially, the PSIs are CMS’s way of saying “this should never happen.” And hospitals are penalized when patient safety events occur.

COVID-19’s Impact on PSI Trends

For a significant amount of time CMS’s approach seemed to be working. The data showed that focusing on patient safety (thus reducing patient harm) resulted in overall decreases in several PSIs. Then the COVID 19 pandemic hit and multiple PSIs increased significantly such as falls, bloodstream infections from central line catheters, and pressure injuries from devices or immobility.

The pandemic and resulting increased acute hospitalizations opened Pandora’s box for patient harm. Per the journal Nursing Research, “Sudden disruptions to the work of nurses required to manage a large volume of high-acuity patients could overwhelm a hospital’s immediate nursing capacity to prevent NSIs (Nursing Sensitive Quality Indicators).” This underscores the importance of prioritizing patient safety and harm reduction as essential in healthcare. 4

PSI Removal & Reporting Exclusions

Several PSI conditions can be avoided in reporting by improving accuracy in documentation and coding helps to relieve the financial burden that reporting a PSI places on hospitals. There are several exclusion diagnoses for many PSIs that, if established by natural documentation or a CDI query , will remove the patient from that PSI bucket. This is how CMS emphasizes that they know some conditions put patients at higher risk of experiencing these outcomes, and these encounters should not be held against this hospital .

Removing a patient from a PSI may also be as simple as querying to ask if a certain diagnosis is present on admission ( POA = “Y” ). Assigning accurate admission status is also critical for PSI reporting as CMS has flagged some of the PSIs to only include Elective admissions.

Ongoing Critique and Future Reform of PSIs

At best, PSIs are meant to track adverse patient outcomes and ensure patient safety. However, some industry and quality leaders have criticized the PSI’s stating:

“AHRQ’s Patient Safety Indicators and related measures have been criticized because they initially failed to focus only on hospital-acquired conditions and because some indicators had relatively high false positive rates. As these concerns were resolved through measure refinements and better data quality (e.g., nearly universal adoption of the “present on admission” indicator), some critiques highlighted the phenomenon known as complexity bias, whereby healthcare organizations attempt to address metrics such as PSIs, by creating separate quality improvement teams that do not effectively coordinate their efforts in a unified model of safe hospital care.” 1

Another common complaint from industry experts is that, despite decreased PSI reporting, CMS will always punish hospitals that perform in the bottom 25% of PSI 90 scores . It is anticipated that CMS will reconsider this performance model in the future and potentially reward hospitals for year-over-year improved performance .

Concerning documentation and coding, those in healthcare are all navigating the complex arena to understanding PSI’s , implementing changes to improve our rankings, and working to achieve sustainable outcomes for our respective organizations.  

Rachel Mack, MSN, RN, CCDS, CDIP, CCS, CRC

Managing Consultant, CDI at UASI

Works Cited

Agency for Healthcare Research and Quality . (n.d.). Patient Safety Indicators. Patient Safety Network (PSNet). Available at: https://psnet.ahrq.gov/primer/patient-safety-indicators

Institute of Medicine . (2000). To Err Is Human: Building a Safer Health System. National Academy Press.

Agency for Healthcare Research and Quality . (n.d.). Technical Specifications for Patient Safety Indicators. Available at: https://qualityindicators.ahrq.gov/measures/PSI_TechSpec

Nursing Research . (2024). COVID-19 pandemic increases in nursing-sensitive quality indicators. Nursing Research, 73(6). Available at: https://journals.lww.com/nursingresearchonline/fulltext/2024/11000/covid_19_pandemic_increases_in_nursing_sensitive.16.aspx

Understanding the Financial Impact of APR DRGs and MS DRGs in Pediatric Care

katie.curry@uasisolutions.com (Katie Curry) — Mon, 23 Jun 2025 15:07:38 GMT

Understanding the Financial Impact of APR DRGs vs MS DRGs in Pediatric Care

In the complex world of hospital reimbursement, the distinction between APR-DRGs and MS-DRGs can mean millions of dollars for healthcare organizations, particularly those serving pediatric populations. These two classification systems may appear similar at first glance, but their approach to severity adjustment creates significant variations in how patient cases are categorized and ultimately reimbursed. For children's hospitals and pediatric units, understanding these differences isn't just about coding accuracy—it's about financial survival in an era of tightening margins.

The Critical Differences Between APR DRGs and MS-DRGs

At their core, both APR DRGs (All Patient Refined Diagnosis-Related Groups) and MS-DRGs (Medicare Severity DRGs) serve the same fundamental purpose: to categorize hospital inpatient cases into groups that reflect similar clinical characteristics and resource utilization. However, the systems diverge sharply in how they account for patient severity. While MS-DRGs, used primarily by Medicare, employ a relatively simple three-tiered approach (no complications/comorbidities, with CCs, or with major CCs), APR DRGs introduce a more sophisticated four-level severity stratification (minor, moderate, major, and extreme) that also incorporates explicit risk of mortality measurements.

This distinction becomes particularly crucial in pediatric care, where patients often present with complex, chronic conditions that don't fit neatly into Medicare's primarily adult-focused severity framework. A premature neonate with bronchopulmonary dysplasia, congenital heart disease, and feeding difficulties might be classified as a straightforward case under MS-DRGs but would be recognized as an extreme severity case under APR DRGs, with reimbursement differences that can exceed 30-40% for the same hospitalization.

Why APR DRGs Matter for Pediatric Financial Viability

The enhanced sensitivity of APR DRGs to pediatric complexity explains why many state Medicaid programs and children's hospitals have adopted this system. Pediatric cases often involve multiple interacting factors, including chronic conditions, developmental delays, nutritional challenges, and social determinants of health, which collectively drive resource utilization but may be overlooked in simpler classification systems. APR DRGs' four-tier severity structure enables more nuanced categorization that better aligns with clinical reality.

Consider two hypothetical patients admitted for asthma exacerbation. Under MS-DRGs, both might be grouped similarly if they meet the MCC criteria. But APR DRGs would differentiate between a child with well-controlled intermittent asthma experiencing a first-time severe attack (likely moderate severity) versus a technology-dependent patient with severe persistent asthma, tracheostomy, and chronic respiratory failure (extreme seriousness). This granularity ensures hospitals caring for the most medically fragile children receive appropriate compensation for the intensive services these patients require.

The Documentation Imperative

The financial implications of these classification differences make robust clinical documentation improvement (CDI) programs essential for pediatric providers. Effective CDI in the APR DRG environment requires moving beyond simple diagnosis capture to comprehensive illness characterization. Documentation must establish:

The interplay between chronic conditions and acute presentations
The cumulative impact of multiple comorbidities
Precise severity assessments for each relevant condition
Clear temporal relationships between conditions and treatments

For example, documenting "respiratory failure" generates some severity credit, but specifying "acute hypoxic respiratory failure secondary to viral pneumonia in a patient with underlying severe bronchopulmonary dysplasia and pulmonary hypertension" paints the complete clinical picture needed for accurate APR DRG assignment. This level of detail doesn't happen by accident - it requires intentional collaboration among clinicians, CDI specialists, and coders.

Strategies for Success in an APR DRG World

Leading pediatric health systems have developed several best practices to optimize APR DRG performance:

Condition-Specific Documentation Frameworks: Creating structured templates for common pediatric scenarios (extreme prematurity, complex chronic disease exacerbations, etc.) that prompt clinicians to address all relevant severity factors.
Real-Time Physician Education: Embedding CDI specialists in clinical units to provide just-in-time feedback on documentation gaps as cases evolve.
Enhanced Query Processes: Moving beyond yes/no queries to structured inquiries that help physicians articulate clinical complexity in reimbursement-relevant terms.
Longitudinal Condition Management: Ensuring chronic disease registries and problem lists are accurate and updated at each encounter to support severity capture.
Coder-Clinician Rounding: Facilitating direct communication between coding professionals and care teams to resolve ambiguities while clinical details remain fresh.

The Bottom Line: Documentation as a Financial Lifeline

For pediatric providers, particularly those relying on Medicaid reimbursement, mastering APR-DRG documentation isn't optional - it's a financial imperative. In an analysis of one children's hospital's case mix, transitioning from MS-DRG to APR-DRG classification increased average reimbursement by 22% for medically complex patients, directly attributable to more accurate severity capture. As payment models continue evolving toward greater risk adjustment, the ability to thoroughly document and code patient complexity will increasingly determine which pediatric programs can sustain the specialized services their patients need.

The path forward requires breaking down traditional silos between clinical care and revenue cycle functions. When physicians understand how their documentation translates into resources for their programs, when CDI specialists speak the language of clinical care, and when coders have access to complete clinical pictures, everyone wins - especially the vulnerable pediatric patients whose care depends on these systems working seamlessly together.

Leah Jeffries, RHIT, CDIP, CCS, CCS-P

Managing Consultant, Strategy at UASI

Billing an Office Visit Without the Patient Present

katie.curry@uasisolutions.com (Katie Curry) — Mon, 16 Jun 2025 12:46:05 GMT

Coding Tip: Billing an Office Visit Without the Patient Present

Can you bill an office visit when the family member attends the appointment in place of the patient?

Under CPT guidelines, an office visit may be billable when a family member or caregiver attends in place of the patient, as long as the patient is already established and documentation requirements are met.

Per 2025 E/M guidelines, time-based coding can apply to visits involving the physician and/or family/caregiver, not just the patient. Further instructions state that it includes both the face-to-face time with the patient and/or family/caregiver and non-face-to-face time personally spent by the physician on the day of the encounter.

Additional tips and guidance:

Confirm Patient Status First: Before billing, verify that the patient is already established in your practice. New patient visits cannot be billed if the patient is not present, even if a family member or caregiver is.
Thoroughly Document : Ensure documentation clearly identifies that the patient was not present, the reason for their absence, the medical necessity of the visit, the topics discussed with the caregiver/family member, time spent (if using time-based coding)
Use Appropriate E/M Code Level : When time-based coding is used, make sure the total time spent on the date of service is documented, including time spent with family/caregiver and relevant non-face-to-face activities, such as reviewing records, documenting in the EHR, or ordering tests

Check for Payer-Specific Limits : Some payers may not allow billing if the patient is not physically present, even if CPT supports it. Medicare, for instance, has historically had stricter interpretations. Always verify policy-specific rules.

Melanie Perrault, RHIA, CDIP, CCS

Senior Consultant, Audit

Works Cited:

CPT Assistant. (2013, March). [Article]. CPT Assistant, 23 (3), 13.

*Note: Always review payer-specific guidance, as interpretations may differ from AMA recommendations

Why Pediatric Patients Matter in CDI

katie.curry@uasisolutions.com (Katie Curry) — Mon, 09 Jun 2025 16:12:34 GMT

Bridging the Gap: Why Pediatric Patients Matter in CDI

In 2025, many hospitals have established robust CDI programs that are firing on all cylinders; with CDI coverage rates typically above 80% in addition to the rise of query rates. However, the focus for most CDI programs continues to be the adult population.

What about Pediatrics?

The question typically becomes whether Pediatric patients are “worth” reviewing by CDI specialists, especially when the hospital isn’t a Children’s Hospital. If hospitals were to begin focusing on pediatrics, then what’s the potential return on investment (ROI) and what are potential barriers hospitals could face?

This discussion explores why it's time to prioritize pediatric patients in CDI strategy by highlighting emerging data, shifting payment models, and common clinical documentation gaps. It also addresses the challenges that must be overcome to improve outcomes, accurately capture severity, and demonstrate both financial and non-financial impact, while providing practical guidance for querying pediatric-specific conditions to support more precise documentation.

Facts regarding Pediatric inpatient admissions:

Between 2004 and 2019, the number and rate of inpatient stays for children aged 0–17 years decreased by 20%. This is the result of a shift to outpatient services as well as increased pediatric care coordination.
This decrease means fewer routine pediatric admissions, making it crucial to maximize reimbursement for the remaining complex cases.

However, pediatric admissions involving complex chronic conditions and pediatric readmissions increased between 2010 and 2016 [ref AHRQ]-
These complex cases need more resources and, if poorly documented, can cause underpayment and financial loss for the hospital.

From a CDI and coding perspective, this means that concurrent CDI reviews are more important than ever, to ensure accurate capture of all acute and chronic conditions for complex pediatric cases. In addition, pediatric patients often present with rare conditions that require precise documentation to support appropriate severity of illness (SOI) and risk of mortality (ROM) scoring, which are metrics that increasingly impact quality reporting and hospital benchmarking.

Payment Models Most Utilized by Pediatric Patients and Why It Matters

As of January 2025, more than 78 million individuals were enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) across all 50 states and D.C. Of these, over 37 million were children enrolled in either CHIP or Medicaid which accounts for 47.5% of total enrollment. [ref Medicaid.gov]

Medicaid is, by far, the most common insurance provider for children, followed by employer-based insurance. Notably, the uninsured rate for children under the age of 19 increased by 0.5 percentage points to 5.8 percent between 2022 and 2023. [ref Census.gov]

Most Medicaid programs are based on the APR-DRG payment system, while many employer-based programs utilize the MS-DRG payment system (or some variation of this). These systems differ significantly, and shifting documentation to impact APR-DRGs requires unique expertise from CDI professionals. Since nearly half of pediatric patients are covered by Medicaid, having CDI specialists who can accurately code and query for APR-DRG payment models is essential to ensure appropriate reimbursement and protect hospital revenue.

Securing Physician Buy-In

Often the first issue to address when beginning Pediatric CDI reviews is unsurprisingly, Physician buy in. CDI and Coding teams often have the best intentions for reviewing and querying Pediatric cases, but without buy-in from the Physician groups, efforts will be futile. Physicians and other providers (like Nurse Practitioners and Physician Assistants) should be introduced to the intention and impact of documentation improvement, how to respond to a query, and given feedback on their performance after the program is established.

Tracking Financial Impact with APR-DRGs

Another potential barrier within Pediatrics is ensuring CDI financial impact is tracked as accurately as possible. As mentioned above, many pediatric patients have Medicaid coverage and utilize the APR-DRG payment system. Many CDI tools are programmed to display only CDI impact on the MS-DRG level or may cost extra to include APR-DRG reporting functionality. Decisions will need to be made at the CDI leadership level for the best way to deal with this, especially when sharing this information with the C-suite.

Measuring Non-Financial Outcomes

Also, CDI teams are now querying for more than financial impact. For example, many teams utilize a variety of risk adjustment tools to maximize the expected mortality score for their patients. However, many existing CDI platforms and analytics tools are not fully equipped to track these non-financial metrics, especially within the pediatric population, which makes it difficult to demonstrate the full value of CDI efforts.

Other avenues of reporting for Pediatrics could include:

Expected mortality score trends (especially after kicking off Pediatric reviews): Tracking changes in expected mortality scores can help demonstrate the clinical accuracy and quality improvements driven by pediatric CDI efforts.
Observed-to-Expected (O/E) capture: Monitoring O/E ratios allows hospitals to assess clinical performance and mortality outcomes, which can influence quality rankings and public reporting.
CC/MCC capture on the MS-DRG level: Improving capture of comorbid conditions or major comorbid conditions ensures appropriate DRG assignment, supports accurate severity profiling, and can affect quality metrics.

Readmission Risk and Documentation Gaps:

Pediatric patients are also the most at-risk population for readmissions. According to the Journal of the American Medical Association (JAMA), as of 2020, pediatric 30-day readmission rates were 11.4%, with costs nearly 1.4 times the cost of an index admission, a ratio higher than for all adult age groups. Ensuring that children with chronic conditions – that are most at-risk for readmission – are reviewed by CDI to establish all complex/chronic conditions in the medical record is vital.

Often a pediatric CDI specialist may initially rely on clinical indicators and concepts commonly used for adults when developing queries. While some conditions overlap depending on the child’s age, this is usually not the case. It’s important to ensure that any query is based on clinical indicators such as labs, vital signs, and signs and symptoms, that are specifically relevant to the pediatric population.

Some common conditions that the pediatric CDI specialist may query for include common respiratory illnesses (e.g. asthma, pneumonia, bronchiolitis, BPD), sepsis, and malnutrition. The severity of malnutrition is like that of the adult population, but it is also important to know the underlying condition, weight-for-age percentiles, and if feeding difficulties are present.

Regarding sepsis, criteria sets include pSOFA and PELOD. A new International Consensus Criteria for Pediatric Sepsis and Septic Shock was published in March 2024 in JAMA based on the Phoenix Sepsis Score. The benefit of the Pheonix score is that the criterion is based on age and that it has usability at the bedside. It is important to note that the Pheonix score is not applicable to newborns or neonates whose postconceptional age is younger than 37 weeks. CDI specialists should review for sepsis indicators, the source, and organ dysfunction that is linked to sepsis in the documentation.

Respiratory conditions commonly require queries for more specificity of the condition. The pediatric patient admitted with asthma should include details like mild, intermittent or persistent, and whether the asthma is in exacerbation or status asthmaticus. Pneumonia should be specified with the viral or bacterial organism linked in documentation or if there is aspiration.

The Takeaway – Pediatric CDI Should be a Hospital Focus

Pediatric patients make up a significant and complex portion of hospital admissions, yet their documentation needs are often under-prioritized in CDI programs. Given the rising clinical and financial importance of accurately capturing chronic conditions, aligning with APR DRG reimbursement, and improving quality outcomes, expanding CDI efforts to include pediatrics is both necessary and valuable. With focused education, the right tools, and strong provider collaboration, hospitals can strengthen documentation practices and improve care for their youngest patients.

Alyce Reavis, RN, MSN, CCDS, CCS

Senior CDI Educator, Consulting Services at UASI

Rachel Mack, MSN, RN, CCDS, CDIP, CCS, CRC

Managing Consultant, CDI at UASI

Rachel has 13+ years of clinical documentation improvement experience and over 17 years in healthcare as a registered nurse. She has built and led CDI programs across multiple health systems and held leadership, education, and consulting roles at Intermountain (formerly SCL Health), Iodine Software, and Vizient. Rachel is a frequent ACDIS and AHIMA presenter, served as president of the Colorado ACDIS chapter, and previously worked as a CVICU nurse at Vanderbilt University Medical Center.

Hemorrhagic Stroke

katie.curry@uasisolutions.com (Katie Curry) — Tue, 03 Jun 2025 20:36:03 GMT

Ischemic vs. Hemorrhagic Stroke: Coding and Documentation Essentials

Hemorrhagic Stroke Overview

Hemorrhagic Stroke: About 13 percent of strokes happen when a blood vessel ruptures in or near the brain. This is called a hemorrhagic stroke. When a hemorrhagic stroke happens, blood collects in the brain tissue. This is toxic for the brain tissue, causing the cells in that area to weaken and die.

Types of Hemorrhagic Stroke

There are two kinds of hemorrhagic stroke. In both, a blood vessel ruptures, disrupting blood flow to part of the brain . Intracerebral hemorrhages (most common type of hemorrhagic stroke): they occur when a blood vessel bleeds or ruptures into the tissue deep within the brain. They are most often caused by chronically high blood pressure or aging blood vessels. Subarachnoid hemorrhages : Occur when an aneurysm (a blood-filled pouch that balloons out from an artery) on or near the surface of the brain ruptures and bleeds into the space between the brain and the skull.

Ischemic Stroke Overview

Ischemic Stroke : The majority of strokes (87%) occur when blood vessels to the brain become narrowed or clogged with fatty deposits called plaque. This cuts off blood flow to brain cells. A stroke caused by lack of blood reaching part of the brain is called an ischemic stroke. High blood pressure is a leading risk factor for ischemic stroke

An ischemic stroke occurs when a clot or a mass blocks a blood vessel, cutting off blood flow to a part of the brain.

Types of Ischemic Stroke

There two main types of ischemic stroke. Cerebral thrombosis is caused by a blood clot (thrombus) in an artery going to the brain. The clot blocks blood flow to part of the brain. Blood clots usually form in arteries damaged by plaque. Cerebral embolism is caused by a wandering clot (embolus) that’s formed elsewhere (usually in the heart or neck arteries). Clots are carried in the bloodstream and block a blood vessel in or leading to the brain. A main cause of embolism is an irregular heartbeat called atrial fibrillation.

Stroke Severity, Neurological Deficits, and NIHSS Documentation

Also code: Report all neurological deficits that occur during the hospitalization, even if they resolve before discharge.

Please pay special attention to laterality . When reading the chart, please try to find specificity regarding whether the deficit affects the dominant or non-dominant side of the body.

Also code: NIHSS Scores : The NIHSS is a neurological exam that is scored on all acute stoke patients. The score describes the severity of the stroke from no stroke (score of zero) to severe stroke (score of 21-24). - info from Coding clinic 4th Q 2016 p.61

Jessica Lutz, MBA, RHIA, CCS
AHIMA Microcredential: Auditing: Inpatient Coding

Senior Consultant, Audit at UASI

Works Cited

American Stroke Association. (n.d.). Types of stroke.
Available at https://www.stroke.org/en/about-stroke/types-of-stroke

American Hospital Association. (2016). NIH Stroke Scale reporting. Coding Clinic for ICD-10-CM, Fourth Quarter, 61.

How the Mid-Revenue Cycle IS The Patient Experience

Tue, 27 May 2025 19:48:16 GMT

How the Mid-Revenue Cycle Impacts the Patient Experience

The Hidden Link Between Financial Workflows & Clinical Outcomes

The mid-revenue within hospitals and health systems is often viewed through a financial or operational lens, typically associated with documentation and coding workflows. When this part of the cycle becomes strained, however, the effects can extend far beyond day-to-day processes. Missed information, unclear documentation, and interruptions in data flow can influence revenue-related outcomes, quality indicators, and even how patients experience your organization.

Because this includes clinical documentation, medical coding, charge capture, and HIM, gaps within this area can affect how clinical activity is translated into administrative records. When these processes are inconsistent or disrupted, the impact becomes visible across several dimensions:

Margin: Incomplete or inaccurate documentation can lead to under-coding, denials, or missed reimbursement.
Compliance: Misaligned documentation can trigger payer scrutiny and administrative follow-up.
Quality: Missing or unclear documentation can influence risk adjustment, clinical quality measures, patient safety indicators, and HCC capture.
Trust & Experience: Documentation gaps or unclear processes can contribute to billing confusion, delays in communication, and experiences that negatively affect patient perception.

For healthcare organizations evaluating how the revenue cycle performance impacts access, accuracy, and outcomes, our mid revenue cycle solutions outline how these functions are operationally supported across the patient journey.

C-Suite Watchouts: Indicators of Revenue Cycle Strain

1. Rising Denials and Revenue Leakage
CFOs should watch for an increase in clinical denials, particularly those tied to documentation or coding issues.

2. Quality Metrics that Don’t Match Clinical Reality
CMOs should be concerned if quality outcomes (e.g., readmissions, risk scores) don’t reflect actual clinical complexity—often a result of poor documentation and HCC capture.

3. Patient Complaints Tied to Financial Experience
CEOs and COOs should pay attention when billing confusion or prior authorization delays become frequent drivers of patient dissatisfaction or attrition.

4. Physician Frustration with Documentation Burden & Financial Impact
CMOs may hear grumbling about clinical documentation tools or workflows. A poor CDI process creates friction with providers—lowering both morale and accuracy and impacting compensation.

Strategic Moves for C-Level Leaders to Improve the Patient’s Experience and Your Operations

CEOs:

Treat mid-rev cycle performance as part of your patient experience and quality agenda.
Connect revenue cycle KPIs to your broader strategy on value-based care, compliance, and growth.

CFOs:

Invest in mid-cycle analytics to track documentation gaps and financial impact.
Align CDI and coding with service line profitability reviews.

CMOs:

Champion a clinical documentation culture—peer education, real-time query support, and physician-facing tools.
Ensure alignment between EHR templates and coding needs to reduce friction.

COOs:

Audit workflows for throughput delays or inefficiencies.
Integrate rev cycle metrics into broader operational dashboards.

Hepatic Thrombus Extending into Atrium

Thu, 22 May 2025 17:20:21 GMT

H ow to code a hepatic thrombus that extends into the atrium.

Two codes would be used:

I82.0 hepatic vein thrombosis
I51.3 Intracardiac thrombosis, NEC

When you index thrombus, you are directed to see thrombosis.

Thrombosis, atrium directs you to see also infarct, myocardium.

This patient did not have a myocardial infarction, therefore it would NOT be appropriate to code that. The sub terms below Thrombosis, atrium are as follows:

*Not resulting in infarction is most appropriate choice.

Atrial thrombosis is listed under I51.3. It says “old” after it in parentheses, but terms in parentheses may be present or absent in the disease you are coding. The terms in the parentheses should not determine whether you use the code or not. ( nonessential modifier)

*each patient scenario is unique – code according to documentation*

References:

OCG Section I.A.7. nonessential modifiers

OCG Section IV.C. accurate reporting of ICD-10-CM diagnosis codes

Beyond HCCs: Why Risk Adjustment Demands a Broader View Across Care Settings

Wed, 21 May 2025 13:43:10 GMT

Insights from ACDIS 2025 Presentation by Kathryn DeVault and Linda Wiseman

When most people hear “risk adjustment,” their minds jump straight to HCCs and Medicare Advantage. But that’s just one piece of a much larger puzzle. Today, risk adjustment plays a critical role not only in outpatient and ambulatory settings but also across inpatient care—and its impact goes far beyond reimbursement. It shapes hospital quality ratings, public perception, and even contract negotiations with commercial payers.

For Clinical Documentation Integrity (CDI) professionals, this means one thing: it’s time to expand the lens. To truly protect their organizations and improve patient outcomes, CDI teams must think strategically about risk adjustment across all care settings—and understand how each setting contributes to the bigger picture of value-based care.

Why This Matters: The Financial Stakes Have Never Been Higher

As healthcare moves steadily from fee-for-service to value-based models, the financial consequences tied to quality metrics have become more severe. Programs like the Hospital Readmissions Reduction Program (HRRP) and Value-Based Purchasing (VBP) directly tie reimbursement to measures like 30-day mortality, readmissions, hospital-acquired infections (HAIs), and patient safety indicators (PSIs).

In this budget-neutral world, CMS withholds a portion of payments—up to 3% under HRRP alone—and only hospitals that outperform national benchmarks get those funds back (and potentially more). This creates a high-stakes environment of financial “winners” and “losers,” where documentation accuracy and risk adjustment play pivotal roles in determining which side your organization lands on.

Risk Adjustment: It’s About Leveling the Playing Field

Risk adjustment ensures fairness by accounting for patient factors like age, chronic conditions, and overall disease burden. Without it, hospitals that care for the sicker, more complex populations would appear to have worse outcomes—penalized not for poor care, but for the very patients they serve.

Tools like the Elixhauser Comorbidity Index and Vizient Clinical Database help calculate expected outcomes based on these patient complexities. This results in an Observed-to-Expected (O/E) ratio that tells the real story: a ratio below 1.0 signals better-than-expected performance; above 1.0 may indicate gaps in care—or gaps in documentation.

CDI’s Expanding Role: From DRG Capture to Strategic Quality Management

Historically, CDI teams focused on ensuring accurate documentation for MS-DRG assignment in hospitals and RAF scores in physician practices. But value-based care has raised the stakes. Accurate documentation now influences quality ratings (like CMS Stars and Leapfrog), public reporting, and even how organizations negotiate contracts with commercial payers.

Take pulmonary hypertension as an example. This diagnosis may not impact the DRG assignment, but it significantly affects risk adjustment calculations for mortality and readmissions. Capturing it accurately changes how a hospital’s performance is judged—and could shield the organization from costly penalties.

This is why CDI reviews must evolve beyond revenue capture. High-impact diagnoses that influence risk models need to be prioritized, even when they don’t change reimbursement directly. CDI professionals also play a vital role in ensuring that only appropriate cases enter mortality and readmission cohorts, directly affecting performance metrics.

Understanding the Tools: Elixhauser, Vizient, and AHRQ Methodologies

Different methodologies apply to different programs and understanding them is key to effective CDI intervention.

Elixhauser Comorbidity Index: Used by CMS, focuses on 38 comorbidity categories derived from secondary diagnoses—many of which must be documented as present on admission.

Vizient Clinical Database: Provides powerful benchmarking data, helping hospitals analyze performance and identify opportunities for quality improvement.

Each methodology has its own nuances, but the common thread is this: documentation must be clinically valid, complete, and precise.

Star Ratings and Public Perception: Why This Is About More Than Money

CMS Star Ratings are public and highly visible. Patients use them. Payers use them. They directly influence a hospital’s reputation, competitive position, and even patient volumes.

These ratings reflect performance across five domains: mortality, safety of care, readmissions, patient experience, and timely/effective care. A poor showing in just one domain—often influenced by incomplete documentation—can drag down an entire rating.

Risk adjustment doesn’t just impact mortality rates; it influences penalties for readmissions, HAIs, and PSI reporting. Inaccurate or incomplete documentation skews these outcomes, exposing organizations to financial loss and public reputational damage.

So, Where Should CDI Teams Focus?

To make the biggest impact, CDI teams should prioritize reviews and queries that address:

DRG Optimization – Capture CCs and MCCs accurately.
Quality Measure Accuracy – Identify diagnoses that impact risk models for mortality and readmissions.
HAC/PSI Prevention – Reduce exposure to costly penalties.
Strategic Queries – Focus on high-leverage diagnoses that don’t always affect reimbursement but dramatically impact quality metrics.

The Bottom Line: Accurate Data Drives Everything

In the end, quality performance, financial success, and even public trust hinge on the accuracy of what’s documented and coded. CDI professionals aren’t just stewards of revenue anymore—they’re central to the organization’s strategy for thriving in a value-based world.

As the healthcare environment grows more complex and margins shrink, the organizations that win won’t just deliver excellent care. They’ll also tell the full and accurate story of that care through precise documentation. And CDI teams will be the ones leading that charge.

The Hospital Revenue Opportunity No One's Talking About

Thu, 15 May 2025 14:16:37 GMT

Why Risk Adjustment Isn’t Just for Payers Anymore: 

The Hospital Revenue Opportunity No One's Talking About

Hospitals are sitting on an untapped revenue opportunity—and it’s hiding in their documentation.

For years, risk adjustment models like CMS-HCC have been the focus of payers and primary care groups. But with the rise of value-based care, ACOs, Medicare Advantage, and hospital-owned physician groups, the conversation is shifting. Risk adjustment is no longer just a payer game. It’s a strategic imperative for hospitals—and CDI leaders are uniquely positioned to lead the charge.

Hospitals are increasingly held accountable for quality outcomes and costs. Programs like Medicare Shared Savings, Bundled Payments, and Health Equity Index measures tie performance and reimbursement to accurate patient acuity reporting. The only way to prove that a patient is as complex as they truly are? Precise, complete documentation.

In other words: If it isn’t captured, coded, and reported—it doesn’t count.

Clinical Documentation Integrity (CDI) programs have traditionally focused on inpatient MS-DRG optimization and denial prevention. But the same CDI teams can—and should—apply those principles to risk-adjusted populations across care settings.

Capturing HCCs and chronic conditions on every encounter
Ensuring specificity in documentation to reflect true patient complexity
Supporting accurate quality and safety metrics (e.g., PSIs, mortality, readmissions)

With hospitals increasingly managing at-risk contracts or working within ACOs and MSSP frameworks, this isn’t optional anymore—it’s strategic.

“We’ve seen hospitals with strong CDI programs increase RAF scores, improve Star Ratings, and reduce denials—simply by shifting focus upstream,” says Rachel Mack, CDI Consultant at UASI.

What Hospitals Are Missing Without It:

Revenue Leakage: Missed HCCs = missed dollars in risk-based models.
Audit Vulnerability: Incomplete documentation makes hospitals an easy target for RADV and OIG audits.
Reputation Risk: Quality metrics based on faulty data can distort a hospital’s actual performance.
Poor Alignment with Medical Staff: Providers don’t always understand how much documentation impacts hospital performance.

CDI Tip: Tumor Lysis Syndrome

Mon, 12 May 2025 17:48:25 GMT

Definition: Tumor lysis syndrome (TLS) is an oncologic emergency caused by massive tumor cell lysis and the release of large amounts of potassium, phosphate, and uric acid into the systemic circulation. Deposition of uric acid and/or calcium phosphate crystals in the renal tubules can result in acute kidney injury.

Cairo-Bishop Definition and Grading System

The Cairo-Bishop definition provides specific laboratory criteria for the diagnosis of TLS both at presentation and within seven days of treatment. There is also a grading system to define the degree of severity of TLS.
Laboratory TLS: any two or more abnormal serum values for uric acid, potassium, calcium, or phosphorus
Clinical TLS: grading system for severity of TLS in patients with laboratory TLS was based on the degree of elevation in serum creatinine, the presence and type of cardiac arrhythmia, and the presence and severity of seizures

ICD-10-CM Codes and Current Coding Advice

E88.3, Tumor Lysis Syndrome
Classifies as an MCC when reported as a secondary diagnosis
When applicable, report an additional code to report adverse effect to identify the drug (T45.1X5)
Prior advice suggests when TLS and CRS are present together that E88.3 and R65.10, SIRS of non-infectious origin, w/o acute organ dysfunction would be reported. However, there are now specific codes to report CRS (D89.831-D89.839)

CDI Clinical Scenario:

HPI: A 25‐year‐old male with newly diagnosed high‐grade Burkitt lymphoma was admitted for induction chemotherapy. He had bulky disease with elevated lactate dehydrogenase (LDH) and an initial workup that documented dehydration. Baseline renal function was normal (serum creatinine 0.9 mg/dL)
On admission, the patient’s workup noted high tumor burden and risk factors for tumor lysis syndrome (TLS), including elevated LDH (2.5× ULN) and a large mediastinal mass. Prophylactic measures were initiated with aggressive intravenous hydration and oral allopurinol.
Chemotherapy Initiation & Onset of TLS: Approximately 18 hours after starting a multiagent chemotherapy regimen (cyclophosphamide, vincristine, and prednisone), the patient developed nausea, vomiting, and left flank pain. His urine output declined, and he reported a new-onset weakness.
Laboratory Findings:
Uric acid: 12 mg/dL (elevated)
Potassium: 5.8 mmol/L
Phosphorus: 8.0 mg/dL
Calcium: 7.0 mg/dL (low)
Creatinine: increased from 0.9 to 1.8 mg/d
Provider documentation upon transfer to the ICU:
“The patient was transferred to the intensive care unit for close monitoring and telemetry. Treatment was escalated to include aggressive IV hydration, a single dose of IV rasburicase (administered four hours before planned continuation of chemotherapy), and supportive electrolyte management. Documentation noted that allopurinol was held once rasburicase therapy was initiated”

CDI Query Example:

Dear Dr. _____,

Using your medical judgment, please clarify the condition that caused ICU admission for this patient.

Tumor lysis syndrome
Other etiology of clinical indicators (please specify)

Clinical Indicators:

Newly diagnosed high‐grade Burkitt lymphoma admitted for induction chemotherapy with initial labs indicating dehydration.
Approximately 18H after chemo, developed nausea, vomiting, and left flank pain. Urine output declined, and he reported new-onset weakness.
Labs: Uric acid: 12 mg/dL (elevated); Potassium: 5.8 mmol/L; Phosphorus: 8.0 mg/dL; Calcium: 7.0 mg/dL (low); Creatinine: increased from 0.9 to 1.8 mg/d
H&P states patient was transferred to the intensive care unit for close monitoring and telemetry. Treatment was escalated to include aggressive IV hydration, a single dose of IV rasburicase (administered four hours before planned continuation of chemotherapy), and supportive electrolyte management. Documentation noted that allopurinol was held once rasburicase therapy was initiated.

References:

Centers for Medicare and Medicaid Services. ICD-10-CM Official Coding Guidelines for Coding and Reporting FY’ 2025. www.cms.gov.
AHIMA, ACDIS (2022). Guidelines for Achieving a Compliant Query Practice (2022 Update).
American Hospital Association. (2020). Coding Clinic ICD-10-CM/PCS, First Quarter 2020; Page 37
Larson, R. (2024). Tumor Lysis Syndrome: Pathogenesis, clinical manifestations, definition, etiology and risk factors. UpToDate.
Larson, R. (2022). Tumor Lysis Syndrome: Prevention and Treatment. UpToDate.

Why Health Information Professionals are Vital: 5 Key Insights

Mon, 12 May 2025 17:00:14 GMT

Why Health Information Professionals are Vital: 5 Key Insights

As we conclude Health Information Professionals (HIP) Week, it's the perfect time to reflect on the vital role of HIP leaders, who serve as the invisible threads that weave together the fabric of our healthcare system. These dedicated professionals play a crucial role in ensuring the healthcare industry operates seamlessly, carefully interlinking accurate patient records, complying with standards and facilitating effective operations. HIPs help improve patient care, support clinical decision-making, and enable valuable research, ensuring the strength of healthcare systems across the country.

Here are 5 key reasons why Health Information Professionals are indispensable to the continued success and evolution of healthcare in the United States.

Ensuring Accurate and Efficient Medical Coding : Health Information Professionals convert details from patient medical records into standardized medical codes, review charts for accuracy, and ensure compliance with regulations. Additionally, they assist in billing and reimbursement and collaborate with healthcare providers to clarify vital information, all of which are crucial for maintaining the integrity of patient records and ensuring efficient healthcare operations.
Maintaining Regulatory Compliance : HIPs help healthcare organizations comply with federal regulations like HIPAA, ensuring that patient information is handled securely and confidentially. This is essential for safeguarding patient privacy and avoiding costly legal and financial penalties.
Supporting Clinical Decision-Making : Accurate and timely health information is key to clinical decision-making. Health Information Professionals ensure that healthcare providers have access to up-to-date, accurate patient data, which supports better patient outcomes by enabling informed decisions.
Facilitating Health Data Analytics and Research : Health Information Professionals manage and analyze vast amounts of healthcare data, which are used in research, epidemiology, and policy-making. Their work helps identify trends, track disease outbreaks, and improve healthcare delivery, ultimately advancing public health.
Improving Operational Efficiency : By organizing and maintaining health records, HIPs improve healthcare facilities’ operational efficiency. This includes streamlining workflows, reducing administrative burdens, and ensuring that patient information is easily accessible when needed, which supports overall healthcare system performance.

At UASI, we deeply appreciate the behind-the-scenes efforts of Health Information Professionals who are essential in ensuring precision, regulatory adherence, and operational effectiveness. Their work forms the backbone of patient care and informed decision-making. Despite often being overlooked, their contributions are vital to the functioning of the healthcare system.

The Silent Driver Behind 4+ Star CMS Ratings

Mon, 12 May 2025 15:57:17 GMT

The Silent Driver Behind 4+ Star CMS Ratings

For Quality Directors, CMS Star Ratings are more than a metric—they reflect a healthcare organization’s commitment to excellence. A 4+ Star CMS rating directly influences plan revenue through quality bonus payments, increased member enrollment, and rebate retention. For Medicare Advantage organizations, even a one-star drop can mean millions in lost revenue, making high ratings essential for financial growth and long-term sustainability.

While many factors influence ratings, documentation is the silent powerhouse that drives accuracy, compliance, and performance.

1) Strengthen Data Integrity & Performance

Incomplete or inconsistent documentation distorts outcomes, masking gaps in patients care and skewing Star Ratings. By standardizing documentation workflows, you:

Capture clinical and operational data reliably
Reduce discrepancies in HEDIS, CAHPS, and Part D reporting
Strengthen the healthcare system's foundation for accurate quality measurement

2) Demonstrate Unwavering CMS Compliance

Regulators scrutinize documentation to validate adherence to CMS regulations. Proactively aligning documentation with CMS requirements:

Mitigates audit risks and avoids costly penalties
Provides clear evidence of policy implementation and care delivery
Builds credibility with regulators and stakeholders

3) Achieve Audit-Readiness Without Last-Minute Scrambles

Audits shouldn’t be a fire drill. Accurate and thorough documentation and workflows ensure:

Easy retrieval of patient records, policies, and corrective actions
Transparent audit trails for measures like Medication Adherence (Part D) and Chronic Condition Management
Confidence in defending your plan’s performance under scrutiny should an audit arise

4) Optimize Outcomes Across Key Clinical and Service Domain Measures

Star Ratings hinge on high-impact areas like medication adherence, preventive screenings, and chronic care management. Strong documentation:

Tracks performance gaps compared to peers and a baseline in real time, enabling timely interventions
Supports care coordination across providers
Validates performance for hybrid and administrative measures

5) Boost Member Satisfaction and Retention

Documentation isn’t just for regulators—it’s a tool for member trust. Clear records of:

Benefits explanations and care plans reduce confusion
Grievances and appeals demonstrate responsiveness
Preventive outreach (e.g., annual wellness visits) improves CAHPS scores

Quality leaders who view documentation as a strategic asset, and not merely a bureaucratic task, unlock its full potential to improve reporting accuracy, enhance compliance, and drive measurable improvements in Star Ratings. This proactive approach not only strengthens data integrity and reduces risk but also directly impacts revenue by maximizing reimbursement tied to Star Ratings performance. By leveraging documentation as a tool for continuous improvement, organizations can build a sustainable path toward higher ratings and long-term financial success.

CDI Reimagined: Improved Patient Care, Quality and 2100M+ Revenue gain in 16 months

Mon, 12 May 2025 14:27:52 GMT

CDI Reimagined: Improved Patient Care, Quality and $200M+ Revenue gain in 16 months

Hospitals today are navigating shrinking margins, workforce constraints, and increasing documentation scrutiny. For one national health system, years of revenue decline revealed a bigger issue: entrenched documentation practices were quietly costing millions.

In partnership with UASI, this organization launched a system-wide CDI optimization initiative — spanning 42 hospitals — that not only delivered $200M+ in revenue improvement but also boosted quality scores, clinical accuracy, and physician engagement. Here's how we did it — and what other health systems can learn from it.

The Importance of CDI in Healthcare

CDI programs serve as a bridge between clinical teams and the financial aspects of healthcare. By ensuring accurate and comprehensive documentation, hospitals can:

Improve patient care through precise diagnoses and treatment records.
Enhance compliance with regulatory and payer requirements.
Optimize hospital reimbursement by capturing the full extent of patient conditions.
Ensure quality and safety indicators accurately reflect patient outcomes.
Reduce claim denials and delays in payment processing.

CDI programs are a cornerstone of revenue cycle management, influencing hospital financial health by identifying opportunities for correct Diagnosis-Related Group (DRG) assignment and reducing documentation-related revenue losses. When documentation of care is incomplete and/or inaccurate, the continuity of care for that patient from physician to physician and visit to visit is broken. This makes CDI not just a revenue program, but a patient safety program as well.

Challenges Facing CDI Programs

Despite their importance, hospitals encounter several obstacles in running efficient CDI programs:

Communication Barriers: The shift to remote CDI teams has weakened communication between physicians and documentation specialists, leading to gaps in documentation quality.

Policy vs. Practice Discrepancies: Leadership often assumes that established policies are followed consistently, but program assessments often reveal inconsistencies due to staff turnover and shifting priorities.

Resource Allocation & Physician Engagement: CDI teams and physicians struggle to manage their ever-expanding list of organizational priorities, leading to overlooked and non-compliant documentation opportunities, inconsistent training, and revenue loss.

Institutional Inertia: Many hospitals adhere to outdated CDI practices, resisting change due to long-standing workflows and organizational habits.

CDI Optimization Project: Methodology & Execution

The active phase of the optimization initiative was conducted over 12 months, covering 42 hospitals. This initiative differs from traditional documentation audits in that it was designed to analyze not just the accuracy of the final coding, but the entire ecosystem that enables the patient record to be coded. An Executive Steering Committee was formed to ensure the program had buy-in and support for such a massive, system-wide undertaking. The comprehensive approach was conducted in a systematic approach as detailed below:

Drive Strategic Alignment Through Executive Leadership Engagement
Uncover Policy Gaps & Insights Through Stakeholder Engagement
Conduct Targeted Chart Audits to Identify Opportunities and Enable Timely Action
Deliver Customized Physician Education to Address Training Needs and Drive Enterprise Consistency
Leverage Data-Driven Insights to Prioritize Efforts and Maximize Impact

Key Outcomes and Measurable Impact

The results of the CDI optimization project were significant from a culture standpoint, improved quality rankings, better patient outcomes, as well as the impact it had on the Client’s financials. There were notable qualitative and quantitative improvements throughout this project that will pay dividends for the foreseeable future.

Financial Improvements:

Recognized over $200 million+ in additional revenue benefit
Over 2,000 positive-dollar DRG changes recommended (~18% of charts audited)
$4,378 per positive-dollar DRG change recommendation
An average of $787 identified per chart audited

Key Takeaways

Treat documentation as a strategic asset — It's not just compliance; it directly impacts clinical accuracy and revenue performance and can be a way to engage physicians

Drive change from the top — Executive alignment and real-time feedback loops are essential for sustainable, system-wide improvements.

Leverage third-party reviews for fresh insight — Even mature CDI programs benefit from objective assessments that reveal hidden opportunities.

Addressing Childhood Obesity: Prevalence Rates and ICD-10-CM Code Revisions

Thu, 17 Apr 2025 15:47:43 GMT

Pediatric Obesity Coding Updates: New ICD-10-CM Codes and BMI Classification Changes

Childhood obesity remains a pressing public health concern in the United States. According to the CDC, approximately 1 in 5 children and adolescents — about 19.7% of those aged 2–19 years—are affected. That’s an estimated 14.7 million young people across the country.

Obesity Trends Among U.S. Youth

Childhood obesity isn’t distributed evenly. Rates vary across age groups , racial/ethnic backgrounds , and socioeconomic status :

By Age
Ages 2–5: 12.7%
Ages 6–11: Data not specified in this summary
Ages 12–19: 22.2%
By Race & Ethnicity
Hispanic: 26.2% (highest prevalence)
Non-Hispanic Black: 24.8%
Non-Hispanic White: 16.6%
Non-Hispanic Asian: 9.0%
By Family Income
Children in households at or below 130% of the Federal Poverty Level (FPL) have a 25.8% obesity rate—highlighting a clear socioeconomic link.

New ICD-10-CM Codes for Pediatric Obesity (Effective October 1, 2024)

To support more accurate diagnosis and classification, the FY 2025 ICD-10-CM updates introduced new and revised codes for pediatric obesity and BMI.

New Obesity Classification Codes

These now distinguish between three classes of obesity , based on BMI:

E66.811 – Obesity, Class 1 (BMI: 30–34.9)
E66.812 – Obesity, Class 2 (BMI: 35–39.9)
E66.813 – Obesity, Class 3 (BMI: ≥40)

Pediatric BMI Code Updates

BMI coding for youth aged 2–19 years is now more detailed, enabling better tracking and clinical alignment with growth charts.

Z68.54 – REVISED: Pediatric BMI at 95th percentile to <120% of the 95th percentile
Z68.55 – NEW: Pediatric BMI at 120% to <140% of the 95th percentile
Z68.56 – NEW: Pediatric BMI at ≥140% of the 95th percentile

Reminder :
Pediatric BMI codes apply to ages 2–19 .
Adult BMI codes are for patients 20+ years .

Why These ICD-10-CM Code Changes Matter

The updated codes aim to:

Improve diagnostic accuracy for healthcare providers.
Align more closely with current pediatric obesity guidelines .
Support better data tracking and research .
Help identify patients at higher risk for comorbidities linked to severe obesity.

Final Thoughts on Pediatric Obesity Coding Updates

These coding updates aren’t just bureaucratic changes—they’re designed to enhance the way we identify, track, and treat obesity in young patients. Accurate coding leads to more personalized care, better public health interventions, and stronger advocacy for at-risk children.

Works Cited:

Centers for Disease Control and Prevention. (2024). Childhood obesity facts. Available at: https://www.cdc.gov/obesity/childhood-obesity-facts/childhood-obesity-facts.html

Centers for Medicare & Medicaid Services. (2024). ICD-10-CM Official Guidelines for Coding and Reporting, FY 2025. Available at: https://www.cms.gov

Centers for Disease Control and Prevention. (2024). New childhood obesity ICD-10-CM codes: Partner promotion materials. Available at: https://www.cdc.gov

New COVID Guidelines

Thu, 17 Apr 2025 15:45:00 GMT

New COVID-19 Coding Guidelines

Effective April 1, 2025

ICD-10-CM updates are here, and with them come some important changes regarding COVID-19 documentation and coding. These update s, found in Chapter 1: Certain Infectious and Parasitic Diseases, fo cus on improving clarity, accuracy, and consistency in how COVID-19 cases are reported. Let’s break down the key takeaways.

Confirmed Cases Only

Code only a confirmed diagnosis of the 2019 novel coronavirus disease (COVID-19).

Use U07.1, COVID-19 only when:
The provider documents a confirmed diagnosis.
There’s a positive COVID-19 test result.

Note: “Confirmation” does not requir e a positive test. If the provider documents that the patient has COVID-19, that alone is sufficient.

Do not assign U07.1 if the documentation includes terms like “suspected,” “possible,” “probable,” or “inconclusive.” Instead, code the signs and symptoms b eing reported.

Reference: Guideline I.C.1.g.1.g

What About Asymptomatic Individuals?

For asymptomatic patients who test positive without a provider-confirmed diagnosis of C OVID-19:

A query should be sent to the provider to determine if the patient truly has COVID-19.
This is b ecause false positives are possible, and the provider’s documentation is necessary to confirm the diagnosis.

Why the Change?

This update helps ensure bett er documentation accuracy, public health tracking, and clinical decision-making. Here' s the rationale:

Provider Judgment is Key
Clinical expertise is recognized as a reliable source, even in the absence of a test.
Built-in Flexibility
Supports timely care even when testing is delayed or unavailable.
Consistency in Reporting
Standardized coding ensures accurate tracking across the healthcare system.
Strong Emphasis on Documentation
Encourages thorough clinical notes regarding symptoms, exposure history, and diagnosis rationale.

Bottom Line

These new guidelines aim to strike the right balance betwee n clinical judgment and coding precision, giving providers the flexibility they need while maintaining the integrity of public health data.

Make sure your team is up to date and coding accordingly!

Understanding Parkinson’s Disease Coding & Clinical Features

Thu, 17 Apr 2025 15:41:13 GMT

Parkinson’s Disease: Tremor vs. Dyskinesia and ICD-10-CM Coding

A recent question to the AHA Coding Clinic asked whether Parkinson’s Disease (PD) with tremor could be coded as Parkinson’s Disease with dyskinesia. The official guidance was clear:

“Codes in subcategory G20.B- , Parkinson’s disease with dyskinesia, should only be assigned when dyskinesia associated with Parkinson’s disease is specifically documented by the provider. ”

ICD-10-CM Updates for Parkinson’s Disease (Effective October 1, 2023)

G20.A1 – Parkinson’s disease without dyskinesia, without mention of fluctuations
G20.A2 – Parkinson’s disease without dyskinesia, with fluctuations
G20.B1 – Parkinson’s disease with dyskinesia, without mention of fluctuations
G20.B2 – Parkinson’s disease with dyskinesia, with fluctuations
G20.C – Parkinsonism, unspecified

Tremor vs. Dyskinesia in Parkinson’s Disease

Both tremor and dyskinesia are movement disorders associated with PD, but they differ significantly in cause, presentation, and treatment. Here's a breakdown:

Tremor in Parkinson’s Disease

Definition: Involuntary, rhythmic, oscillatory movement of a body part

Typical Type in PD: Resting tremor — appears when the body part is at rest and improves with movement

Characteristics:

Frequency: 4–6 Hz
Location: Commonly begins in one hand (e.g., “pill-rolling” tremor between thumb and fingers)
Asymmetry: Often starts on one side of the body
Triggers: Worse at rest, improves with movement or posture

Cause: Dopamine depletion in the basal ganglia

Treatment:

Dopaminergic medications (e.g., Levodopa)
Deep Brain Stimulation (DBS) in advanced cases

Dyskinesia in Parkinson’s Disease

Definition: Abnormal, involuntary movements that are fluid, dance-like, or jerky

Type in PD: Levodopa-induced dyskinesia (LID) — occurs as a side effect of long-term levodopa therapy

Characteristics:

Timing: Occurs at peak dopamine levels or during medication transitions
Appearance: Chorea (random jerky movements), dystonia (sustained contractions), or both
Location: May involve limbs, trunk, or face
Triggers: High-dose or long-term levodopa use

Cause: Pulsatile dopamine stimulation causes maladaptive changes in the basal ganglia

Treatment:

Adjusting levodopa (e.g., smaller, more frequent doses)
Adding adjunct therapies (amantadine, dopamine agonists)
Advanced options: DBS or continuous infusion (e.g., Duodopa)

Key Clinical Differences Between Tremor and Dyskinesia

Nature:

Tremor: Rhythmic and oscillatory
Dyskinesia: Irregular, flowing, or jerky

Timing:

Tremor: Worse at rest, better with movement
Dyskinesia: Tied to medication timing (often peak-dose)

Cause:

Tremor: Dopamine deficiency
Dyskinesia: Long-term use of levodopa

Treatment Focus:

Tremor: Dopamine replacement
Dyskinesia: Medication adjustment or adjuncts

Clinical Pearls for Documentation and Coding

Tremor is a core symptom of Parkinson’s and may be present at diagnosis.
Dyskinesia is typically a treatment-related complication , appearing after years of therapy.
Proper distinction between tremor and dyskinesia is essential for correct coding and treatment planning.

Coding Clinic Clarification on Parkinson’s Disease Symptoms

“Parkinson’s disease is a progressive neurodegenerative condition presenting with motor symptoms (e.g., tremors of hands, arms, legs, or head) and non-motor symptoms (e.g., depression, anxiety, pain).

Dyskinesia is defined as involuntary movements of the face, arms, legs, or trunk.

Fluctuations refer to alternating ON episodes (positive response to levodopa) and OFF episodes (return of symptoms as medication wears off).”

Works Cited

American Hospital Association. (2023). Parkinson’s disease with tremor vs. dyskinesia. AHA Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2023.

American Hospital Association. (2023). ICD-10-CM code updates for Parkinson’s disease. AHA Coding Clinic for ICD-10-CM/PCS.

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)

Thu, 17 Apr 2025 15:36:24 GMT

SIADH: Clinical Indicators, Documentation, and Coding Guidance

Syndrome of Inappropriate Antidiuretic Hormone (SIADH) occurs when the pituitary gland releases excessive antidiuretic hormone (ADH), leading the body to retain fluid and dilute sodium levels in the bloodstream. This condition causes hyponatremia and hypo-osmolality, often triggering a complex clinical picture.

Common Causes and Risk Factors for SIADH

What Causes SIADH?

SIADH can develop in response to several underlying conditions or external factors:

CNS disturbances: Stroke, hemorrhage, infection, and trauma can trigger abnormal ADH release.
Cancer: Especially small cell lung cancer, extrapulmonary small cell carcinomas, head and neck cancers, and olfactory neuroblastomas.
Medications: SSRIs, NSAIDs, opiates, some antineoplastic drugs, ciprofloxacin, haloperidol, and high-dose imatinib.
Surgery: Often linked to pain response.
Hormonal deficiencies: Including hypothyroidism and hypopituitarism.
Exogenous hormone use: Vasopressin, desmopressin, and oxytocin.
HIV infection
Hereditary SIADH

Diagnostic Criteria for SIADH (Schwartz and Bartter)

A diagnosis of SIADH typically includes:

Serum sodium < 135 mEq/L
Serum osmolality < 275 mOsm/kg
Urine sodium > 40 mEq/L
Urine osmolality > 100 mOsm/kg
Normal skin turgor and blood pressure (absence of clinical volume depletion)
Exclusion of other hyponatremia causes
Correction of sodium levels via fluid restriction

Important Note: Code only the SIADH, not the hyponatremia, as hyponatremia is considered integral to the disease process .

Clinical Scenario Illustrating SIADH

A 68-year-old male presents to the ED with confusion, nausea, and a 12-pound weight gain over the past week. He was diagnosed with small cell lung cancer two months ago.

Vitals:

BP: 160/90 mmHg
HR: 110 bpm

Labs:

Serum sodium: 122 mEq/L
Serum osmolality: Decreased
Urine: Elevated osmolality and high sodium concentration

Indicators Supporting a Diagnosis of SIADH

Hyponatremia: Sodium level of 122 mEq/L
Diluted Serum Osmolality: From water retention
Concentrated Urine: High osmolality and sodium levels despite low serum sodium
Recent Weight Gain: 12 lbs in one week, pointing to fluid overload
Underlying Malignancy: Small cell lung cancer is a well-known cause of ectopic ADH production

CDI Documentation Tips for SIADH

1. Accurate Diagnosis

Clearly state “SIADH” and link it to the underlying cause , such as cancer.

2. Clinical Findings

Review provider and nursing notes for symptoms like confusion, nausea, and fluid retention.
Confirm vital signs and weight gain.
Include lab values: sodium, serum/urine osmolality, and urine sodium.

3. Treatment Plan

Document fluid restriction orders .
Check MAR for medications such as vasopressin receptor antagonists .
Note any improvements in symptoms and lab values after treatment.

Tip: High blood glucose can artificially lower serum sodium levels. Use a sodium correction calculator to determine the true sodium level.

Linda Wiseman, BSN, RN, CCDS

Director, CDI Services

Linda is a consulting director with broad experience in CDI, healthcare information technology, and clinical documentation management. Her background includes serving as Senior Director of Consulting at Vizient, where she led major CDI and documentation initiatives across diverse health systems. A CCDS-certified professional and ACDIS 2025 speaker, she brings strong clinical and technical expertise to improving documentation quality, workflow efficiency, and coding accuracy.

Works Cited

Centers for Medicare & Medicaid Services. (2024). ICD-10-CM Official Coding Guidelines. Available at: https://www.cms.gov

Pinson, R., & Tang, C. (2024). The CDI Pocket Guide. Available at: https://www.cdiplus.com

Prescott, L., & Manz, J. (2024). ACDIS CDI Pocket Guide. Available at: https://www.acdis.org

Sterns, R. (2024). Pathophysiology and etiology of SIADH. UpToDate. Available at: https://www.uptodate.com

Yasir, M., & Mechanic, O. J. (2023). Syndrome of inappropriate antidiuretic hormone secretion. StatPearls Publishing.

CDI Tip of the Month - Late Effects of Cerebral Vascular Accident

Thu, 17 Apr 2025 15:32:57 GMT

Understanding Stroke and Its Long-Term Impact

Stroke is the third most common cause of disability and the second most common cause of mortality worldwide. The global 30-day fatality rate following an initial ischemic stroke is estimated at 16–23% .

A U.S. study of 220 ischemic stroke survivors revealed a range of neurologic deficits at six months post-stroke, including:

Hemiparesis (50%)
Cognitive defects (46%)
Hemianopia (20%)
Aphasia (19%)
Sensory deficits (15%)

Additionally, survivors experienced long-term disabilities such as:

Depression (35%)
Inability to walk without assistance (31%)
Institutionalization (26%)
Bladder incontinence (22%)

What is a Stroke?

A stroke , also known as a cerebrovascular accident (CVA) , occurs when the blood supply to part of the brain is interrupted or reduced , preventing brain tissue from receiving oxygen and nutrients. As a result, brain cells begin to die within minutes .

Types of Strokes

Ischemic Stroke
The most common type, accounting for approximately 87% of all strokes. It occurs when a blood clot blocks or narrows an artery leading to the brain.

Hemorrhagic Stroke
Occurs when a blood vessel in the brain bursts , leading to bleeding in or around the brain .

Common Late Effects of CVA

Physical: Hemiplegia, hemiparesis, dysphagia, ataxia
Cognitive: Memory loss, attention deficits, executive function impairments
Speech and Language: Aphasia, dysarthria
Sensory: Visual field loss, neglect (lack of awareness of one side of the body)
Emotional and Behavioral: Depression, anxiety, personality changes
Other: Bladder and bowel control issues, fatigue

Recrudescence of Stroke Symptoms

Recrudescence refers to the reappearance of previously resolved neurological deficits from a prior stroke. These symptoms are typically mild , short-lived , and not due to a new stroke .

Key considerations:

Recrudescence is coded as a “late effect of stroke.”
Follows the same coding and sequencing guidance as the principal diagnosis (PDX).
Can be reported alongside a new acute infarction , if applicable.
Clarity in documentation is essential to accurately capture the etiology of stroke-related symptoms— query the provider if necessary.

Query Example for Clarification

Dear Dr. Carlson ,
Patient with PMH of CVA. Per H&P, admitted with “dysphagia.” Other diagnoses include severe malnutrition, with plans for a PEG tube.

Can this patient’s dysphagia be specified as the most likely cause? For example:

Dysphagia is recrudescence of previous stroke
Dysphagia related to other (please specify) ___
Unknown/undetermined

Other clinical indicators/treatment from the patient’s record:

H&P notes: “dysphagia, severe malnutrition, and failure to thrive. ST/PT/OT to see. Family thinks dysphagia has been going on for a while.”
Treatment: RD consult, PEG tube placement, PT/OT/ST

Why It Matters:

A favorable query response could shift the DRG from DRG 392 (Esoph, gastro, and misc digestive disorders w/o MCC) with the PDX of dysphagia , to DRG 057 (Degenerative nervous system disorders w/o MCC) with the PDX of weakness/dysarthria as a late effect of CVA .

Protecting Your Revenue Cycle: The Role of Outsourcing During Coder Absences

Tue, 08 Apr 2025 14:41:58 GMT

How to Maintain Coding Continuity During PTO and Leave of Absence

Why Coding Disruptions Impact the Revenue Cycle

When medical coders take PTO or a leave of absence, hospitals and healthcare entities can face the risk of disruptions in their revenue cycle. Medical coding is a critical part of the revenue cycle management process because it ensures that the healthcare provider is reimbursed for the services rendered. Disruptions in the coding process can cause delays, errors, and inaccuracies in billing, which directly impacts cash flow and financial health.

To mitigate this risk, hospitals often rely on consultant vendors or outsourcing partners that specialize in providing temporary coverage for coding functions. These agencies are invaluable tools for hospitals looking to cover medical coders during PTO or leave periods and offer several benefits to healthcare systems needing to augment their staff.

Benefits of Using Outsourcing Vendors for Coding Coverage

1. Credentialing, Certification, Quality, and Compliance:

Outsourcing coding to a vendor with the necessary certifications, such as Certified Professional Coder (CPC) or Certified Coding Specialist (CCS), and relevant experience ensures high-quality, accurate, and compliant coding. Certified coders possess the expertise to interpret complex medical records and apply the correct codes according to the latest coding guidelines, reduce the risk of errors or claims denials, and can ensure quality is aligned with current standards. In addition, outsourced vendors often implement strict adherence to HIPAA regulations for data security and patient privacy.

2. Maintaining Continuity and Reducing Revenue Delays:

By relying on specialized vendors or agencies, hospitals can prevent a backlog of uncoded or unbilled accounts. Without this continuity, DNFB and DNFC accounts could quickly accumulate, delaying the revenue cycle and resulting in cash flow problems. Outsourcing can help the hospital maintain its revenue stream and minimize delays in claim submissions.

3. Scalability & Turnaround Time:

Outsourcing partners offer scalability, meaning they can quickly adjust the volume of work they take on depending on the hospital’s needs, whether the absence is short-term (like PTO) or longer-term (such as an extended leave). This flexibility ensures that coding tasks are handled promptly without overburdening the hospital’s existing staff.

4. Cost-Effectiveness and Reduced Burden on Internal Resources:

Outsourcing can be more cost-effective than hiring temporary in-house coders or paying for overtime to cover coder absences. Hospitals can avoid the overhead costs associated with recruiting, training, and compensating temporary employees. Instead, they can rely on external partners who are already trained and ready to step in. This not only reduces the financial strain but also prevents burnout among internal coding staff, who might otherwise be required to manage additional workload during periods of absence.

5. Communication and Reporting:

Outsourcing coding to a vendor with a dedicated account manager offers hospitals clear, consistent communication and proactive support. The manager coordinates regular check-ins to track coding progress and monitor DNFB/DNFC reports, ensuring timely, accurate completion. This approach helps hospitals manage their revenue cycle efficiently, minimize disruptions, and maintain timely reimbursement while fostering a strong vendor partnership.

UASI Solutions Welcomes Donna Sherburne as Director of Coding Services

Tue, 08 Apr 2025 14:36:19 GMT

UASI Solutions, a leader in health information management and revenue cycle solutions, is pleased to announce the appointment of Donna Sherburne as the new Director of Coding Services. Sherburne joins UASI from The Coding Network, bringing a wealth of expertise and a proven track record of leadership in medical coding and compliance.

With over 20 years of experience in the healthcare industry, Sherburne has consistently demonstrated her ability to enhance coding operations, ensure compliance, and drive excellence in healthcare revenue cycle management. Her knowledge and strategic approach will further strengthen UASI’s commitment to providing industry-leading coding solutions that support healthcare organizations in achieving accuracy, efficiency, and financial integrity.

“Donna’s extensive experience and dedication to coding excellence align perfectly with UASI’s mission to deliver high-quality solutions to our clients,” said Chief Operating Officer, Josh Tracy. “Her leadership will play a key role in advancing our coding services, ensuring that our clients continue to receive best-in-class support tailored to the ever-evolving healthcare landscape.”

Sherburne’s addition to the UASI team underscores the company’s ongoing investment in top-tier talent and its commitment to staying at the forefront of industry advancements. By leveraging her expertise, UASI will continue to provide innovative solutions that help clients navigate regulatory complexities, optimize coding accuracy, and enhance overall operational performance.

“I am thrilled to be joining UASI and look forward to collaborating with the team to drive continued excellence in coding services,” said Sherburne. “UASI’s reputation for quality and client-focused solutions aligns with my passion for ensuring the highest standards in medical coding and compliance.”

Sherburne’s appointment is part of UASI’s strategy for growth and innovation in mid revenue cycle consulting and outsourced services. As the company continues to expand its offerings and enhance its solutions, the addition of top industry professionals like Sherburne will reinforce UASI’s position as a trusted partner for healthcare organizations nationwide.

UASI Solutions Welcomes Jim Sowar to Board of Directors

Tue, 08 Apr 2025 14:33:32 GMT

FOR IMMEDIATE RELEASE

UASI Solutions Welcomes Jim Sowar to Board of Directors

Cincinnati, OH — March 31, 2025 — UASI Solutions, a leading national provider of revenue cycle solutions for healthcare organizations, is pleased to announce the appointment of Jim Sowar to its Board of Directors. Mr. Sowar brings over three decades of experience in the healthcare sector, having served as the National Tax Leader for the Health Care Provider sector at Deloitte and as the Managing Partner for Deloitte's Cincinnati office.

"We are thrilled to welcome Jim to our Board," said Nancy Koors, CEO at UASI Solutions. "His extensive expertise in healthcare and his deep understanding of the industry's complexities will be invaluable as we continue to enhance our services and support healthcare organizations as they navigate increased financial pressures, technology and outsourcing opportunities nationwide."

Throughout his career, Mr. Sowar has demonstrated a commitment to excellence and leadership. He has been instrumental in advising healthcare clients on a range of issues, including community benefit reporting, corporate structuring, and compliance matters. His insights have been featured in various industry publications, and he has been recognized for his contributions to the field.

"I am honored to join the Board of UASI Solutions," said Mr. Sowar. "UASI has a strong reputation for delivering high-quality revenue cycle solutions to healthcare providers. I look forward to collaborating with the team to further the company's mission and contribute to its continued success."

UASI Solutions has been empowering healthcare organizations with mid-revenue cycle solutions for over 40 years. The company's comprehensive services are designed to optimize revenue, enhance compliance, and improve operational efficiency for healthcare providers across the nation.

About UASI Solutions

Founded in 1984, UASI Solutions is a nationally recognized leader in the mid revenue cycle. The company offers a comprehensive range of healthcare consulting and solutions, including coding services, clinical documentation improvement (CDI), risk-based services, and revenue integrity. UASI is dedicated to helping healthcare facilities achieve correct reimbursement, maintain compliance, and improve operational efficiency.

Provider Queries 101 – A Quick Guide to Help Providers Understand the Purpose & Benefits of Queries

Tue, 25 Mar 2025 12:55:37 GMT

Understanding Physician Queries and Their Role in Clinical Documentation

Why Physician Queries Are Essential to Clinical Documentation

Physician queries are often misunderstood. A common question from providers is: “Why am I being asked this, and what is this query for?” While physicians are experts in delivering care, clinical documentation requires a different level of specificity to support accurate coding, quality reporting, and reimbursement.

Accurate documentation ensures that the patient’s condition is clearly represented, supports continuity of care, and allows healthcare organizations to meet regulatory and reporting requirements. Within this process, physician queries serve as a key tool for clarifying gaps, inconsistencies, or ambiguities in the medical record.

Why Physician Queries Are Essential to Clinical Documentation

Precise and complete documentation is critical for appropriate reimbursement, quality measurement, and consistent treatment planning. When documentation is unclear or incomplete, it can affect not only coding accuracy but also how a patient’s condition is interpreted across the care team.

Physician queries help bridge this gap by ensuring that documentation aligns with clinical indicators and reflects the full picture of the patient’s condition.

What a Physician Query Is and Why It Matters

A physician query is a communication tool used by coding and Clinical Documentation Integrity (CDI) professionals to request clarification about the medical record. Rather than being a correction mechanism, queries are intended to ensure that documentation accurately reflects the care provided.

When understood in this context, queries can shift from being perceived as administrative interruptions to being recognized as an important part of patient safety and accurate reporting.

Common Reasons Physicians Receive Queries

Queries are typically generated when documentation lacks specificity, contains conflicting information, or does not fully support a diagnosis or procedure. These situations often arise in complex cases where multiple conditions or treatments must be clearly defined.

By addressing these gaps, queries help ensure that the medical record is consistent, complete, and aligned with clinical findings.

Types of Physician Queries and When They Are Used

There are several common types of physician queries, each designed to address a specific documentation need.

Diagnosis clarification queries are used when clinical indicators suggest a condition that has not been explicitly documented. For example, symptoms and test results may support a diagnosis of sepsis, but the condition is not clearly stated in the record.
Procedure clarification queries ensure that documentation accurately reflects how a procedure was performed, such as whether it was open or laparoscopic, which can affect coding and reporting.
Conflicting documentation queries address inconsistencies within the medical record, such as differing diagnoses noted in separate provider entries.
Present-on-admission (POA) queries determine whether a condition existed at the time of admission, which has implications for quality metrics and reporting.
Cause-and-effect relationship queries are used to confirm associations between conditions, helping ensure that documentation reflects the clinical relationship between diagnoses.

How Physicians Can Respond to Queries More Effectively

Timely and accurate responses to queries play a critical role in maintaining efficient workflows and preventing delays in billing. When physicians provide clear and specific documentation, it reduces ambiguity and supports accurate coding.

Engaging with CDI professionals can also improve understanding of documentation expectations and reduce the need for future queries. Ongoing education on documentation standards and coding updates further supports consistency and accuracy over time.

The Impact of Physician Queries on Reimbursement and Quality

The impact of physician queries extends beyond documentation clarity. One health system study found that 42% of query responses resulted in a change to the MS-DRG, contributing to nearly $9.8 million per month in reimbursement tied to improved documentation. These findings highlight how accurate and complete documentation directly influences both financial performance and quality reporting.

Strengthening Documentation Through Better Query Practices

As healthcare organizations continue to focus on quality, compliance, and financial sustainability, physician queries will remain an essential part of the documentation process. When approached collaboratively, queries support a more accurate representation of patient care, improve communication across teams, and reinforce the importance of complete and consistent clinical documentation.

Works Cited:

Association of Clinical Documentation Integrity Specialists. (2014). Determine when and how to query physicians. Available at: acdis.org/articles/determine-when-and-how-query-physicians

AGS Health. (2021). A look at the top clinical documentation integrity trends from 2021. Available at: agshealth.com/blog/a-look-at-the-top-clinical-documentation-integrity-trends-from-2021

American Health Information Management Association. (2022). Guidelines for achieving a compliant query practice (2022 update). Available at: acdis.org/system/files/resources/ACDIS%20AHIMA%20Guidelines%20for%20a%20Compliant%20Query%202022_addendum%202023.pdf

Tackling the Surge in Healthcare Denials

Thu, 20 Mar 2025 17:08:42 GMT

The Rising Challenge of Healthcare Denials

Healthcare denials are increasing at an alarming rate, creating significant challenges for providers. According to the 2023 Change Healthcare Denials Index, denial rates have risen to 10-15% , up from 6-10% a decade ago.

This trend places a strain on revenue cycles, as denials now account for 3-5% of net patient revenue and cost $25 to $50 per claim to rework. For larger health systems, this translates to millions in lost revenue annually .

Denials often stem from:

Eligibility issues
Coding errors
Incomplete documentation
Untimely filing
Duplicate claims
Non-covered services

These issues delay reimbursements, increase administrative costs, and disrupt cash flow—especially for smaller practices.

Why Are Denials Increasing?

Several key factors are driving the rise in healthcare denials:

1. Stricter Payer Requirements

Payers are enforcing more rigorous guidelines, including prior authorization , detailed medical necessity documentation , and precise coding accuracy . Automated claim review systems are flagging and denying claims at an increasing rate.

2. Regulatory Complexity

Frequent updates to ICD-10 and CPT coding standards , along with policies like the No Surprises Act , add administrative burdens that increase the chance of claim processing errors.

3. Workforce Shortages

Staffing shortages and turnover in coding and billing departments lead to backlogs and mistakes. Many organizations still rely on outdated systems , lacking AI-powered claim scrubbing or predictive analytics .

4. High-Deductible Health Plans (HDHPs)

As more financial responsibility shifts to patients, eligibility verification challenges and higher patient payment denials have become prevalent.

Strategies to Reduce Healthcare Denials

To mitigate the impact of rising denials, organizations can implement the following data-driven strategies :

1. Strengthen Front-End Processes

Verify eligibility and obtain prior authorizations early
Ensure accurate patient information collection

2. Improve Coding and Documentation

Invest in staff training and clinical documentation improvement (CDI) programs
Utilize computer-assisted coding (CAC) tools

3. Leverage Technology

Implement AI-powered claim scrubbing
Use predictive analytics and automated denial management workflows

4. Monitor Denial Data

Track denial rates by payer and reason
Establish key performance indicators (KPIs) and conduct regular audits

5. Foster Collaboration

Break down silos between revenue cycle teams
Create cross-functional groups to address root causes

6. Engage Payers

Build strong relationships with payers
Negotiate clearer contract terms and resolve disputes efficiently

7. Enhance Patient Communication

Educate patients about their financial responsibilities upfront
Provide transparent billing statements and assistance with resolving denied claims

The Future of Denial Management

As healthcare complexity grows, denial rates are likely to continue rising . However, emerging technologies like AI, automation, and enhanced price transparency tools offer hope for reducing denials. Regulatory reforms aimed at simplifying billing processes could further alleviate the burden.

By adopting proactive denial management strategies , investing in technology , and improving internal processes , providers can minimize denials and strengthen their revenue cycles —ensuring long-term financial sustainability and better patient care .

Need Help Reducing Denials?

UASI offers expert support in denial management and process optimization . Our tailored solutions help reduce denials, improve cash flow, and safeguard your organization's financial health.

�� Get in Touch: info@uasisolutions.com
�� Learn More: www.uasisolutions.com

Balancing Financial Adjustments and Patient Care Amidst Recent Cuts to the Federal Navigator Program

Thu, 20 Mar 2025 17:08:41 GMT

Balancing Financial Adjustments and Patient Care Amidst Recent Cuts to the Federal Navigator Program

On February 14, CMS released a statement announcing cuts to the Federal Navigator Program . These cuts highlight the Trump administration's broader efforts to reduce federal spending on healthcare programs, which will negatively affect patient care and the financial stability of healthcare systems across the country.

The CMS Federal Navigator Program is an initiative designed to aid individuals seeking health insurance coverage through the Health Insurance Marketplace through Federally-Facilitated Exchanges (FFEs). Navigators offer free, unbiased help with understanding healthcare options, applying for coverage, and understanding eligibility for financial assistance. This program aims to improve access to health insurance and help consumers make informed decisions about their healthcare options. Revenue cycle leaders will need to adapt to the changes in enrollment patterns and understand the broader impact on reimbursement models while prioritizing access to free and affordable healthcare.

Reduced Navigator funding could lead to fewer enrollments in health plans through the FFEs, affecting the number of patients covered by marketplace insurance and altering payer mix. This shift may require mid-revenue cycle leaders to closely monitor enrollment patterns and adjust revenue projections. While lower premiums might benefit individuals without subsidies, those relying on subsidies could face higher out-of-pocket costs, impacting their ability to afford care. Healthcare providers will need to adapt billing and collections strategies to account for fluctuations in premiums and subsidies, while also managing potential changes in reimbursement rates. To navigate these challenges, providers may need to invest in patient education, outreach, and additional support staff to assist with the enrollment process and handle increased claims-related inquiries.

The Consequences of Funding Cuts for Low Income Families

In addition, the recent reduction in funding for the ACA Navigator program has several implications for low-income families, particularly those who rely on the assistance Navigators provide to access affordable health insurance. The reduction in funding for the Navigator program will make it more difficult for low-income families to access enrollment assistance, creating barriers that could result in missed opportunities or coverage gaps. While some individuals may benefit from lower premiums, those relying on subsidies will likely face challenges navigating changes in the marketplace, which could lead to confusion and increased out-of-pocket costs if they select the wrong plan. Without the personalized support Navigators provide, families may turn to less effective resources, exacerbating stress and potentially worsening health disparities, ultimately impacting long-term health equity and outcomes for low-income individuals.

Mid-revenue cycle leaders can take proactive steps to prepare for the changes in the ACA Navigator program while ensuring that patient care for low-income households remains a priority.

4 Ways Mid Revenue Cycle Leaders Can Balance Financial Adjustments with a Focus on Patient Care

1. Strengthen In-House Patient Support Services

Given the reduced funding for Navigators, mid-revenue cycle leaders can enhance in-house support services to help patients navigate the enrollment process. This can include:

Hiring or training dedicated enrollment assistance staff : Building a team that can assist low-income families with enrollment, understanding coverage options, and verifying eligibility for subsidies or plans.
Expanding patient education initiatives : Offering workshops or one-on-one consultations to educate patients on health insurance options, eligibility for subsidies, and plan selection.

2. Partner with Local Community Organizations

Since Navigators historically worked closely with local organizations, mid-revenue cycle leaders should consider forming partnerships with trusted community-based organizations that already serve low-income populations. These partnerships can help ensure families continue to receive the help they need in understanding and accessing coverage options and could include:

Collaborative outreach programs : Leveraging existing community networks to disseminate information about open enrollment, new subsidies, and ACA updates.
Shared resources : Working with nonprofit organizations, churches, and other local services to provide enrollment guidance and ensure low-income families aren’t left without support.

3. Implement Streamlined Enrollment Processes & Leverage Technology

To help reduce barriers, mid-revenue cycle leaders can streamline their own enrollment and registration processes for low-income patients. By making the process easier to navigate and embracing streamlined technology, healthcare organizations can minimize the confusion that might arise due to fewer available Navigators. This can involve:

Simplified documentation and dedicated enrollment windows : Simplify documentation and verification with self-service tools, pre-populated forms, and assistance, while offering flexible enrollment windows to accommodate patients' work and daily schedules.
Automated reminders and enhanced online tools: Ensure your patient portal includes user-friendly tools for browsing insurance options, checking subsidy eligibility, and enrolling in ACA plans, while using automated reminders and follow-ups to keep patients on track with deadlines and required documentation.

4. Monitor and Adjust Payer Mix and Reimbursement Strategies

As changes to ACA enrollment and funding affect the payer mix, mid-revenue cycle leaders should closely track and forecast shifts in their patient population. By keeping a close eye on the financial side, mid-revenue cycle leaders can help their organizations remain financially stable even if enrollment numbers shift.

Preparing for the potential drop in enrollment via the Navigator program means:

Reassessing payer contracts : Ensure that reimbursement rates align with changes in patient demographics, including any shifts between subsidized and unsubsidized patients.
Planning for financial impacts : Work closely with finance teams to account for potential reductions in subsidies and how this might impact overall revenue.

UASI Appoints Josh Knepfle as New Chief Technology Officer

Thu, 20 Mar 2025 17:08:39 GMT

UASI is proud to announce the appointment of Josh Knepfle as the new Chief Technology Officer . With an extensive background in technology leadership, Knepfle brings over 20 years of experience in software development, strategic innovation, and cross-functional team management to the role.

Knepfle joins UASI from his most recent position as CTO at Roadtrippers, where he led the development of innovative mobile and web applications. Before his tenure at Roadtrippers, Knepfle had an extensive career as CTO and Senior Vice President of Engineering at SparkPeople, Inc., an innovator in health and wellness ,where he led the strategy and development of SparkPeople's technology platform Knepfle’s leadership in strategic planning, cloud based solutions AI, scaling technology solutions, and cybersecurity makes him a natural fit to drive UASI's goals of continuous innovation.

As CTO, Knepfle will be responsible for overseeing UASI’s technology strategy and driving product development. His expertise in Agile practices, DevOps, and IoT initiatives, is expected to play a key role in UASI's next phase of growth.

“I joined UASI because I was excited about their vision to drive technological improvements to provide efficient and effective solutions to the health care industry. UASI is committed to being a contributor to making the healthcare system better and technology can play a key role along with UASI’s remarkable services. I was also impressed by UASI’s high standards in cybersecurity, and I like to be on a team that sets high standards.”

Knepfle’s appointment reinforces UASI's commitment to technological advancement, security and enhancing operational excellence across its teams to ensure optimized client solutions.

Leah Jeffries Appointed as Managing Consultant, Strategy at UASI

Thu, 20 Mar 2025 17:08:38 GMT

UASI is excited to announce the appointment of Leah Jeffries as Managing Consultant of Strategy. With over a decade of experience in healthcare coding and compliance, Leah brings a wealth of expertise to this role. She has held several Coding Operations and Strategic Account Management positions where she enhanced client satisfaction, streamlined processes, and led healthcare organizations to optimize their revenue cycle.

“UASI’s 40-year commitment to improving revenue cycle operations and performance was one of the factors that attracted me to this position. Their history, along with their vision for helping health systems enhance quality, compliance, operational efficiency, reduce denials, and improve financial performance aligns with my personal passion and experience. UASI is reinventing themselves and I’m excited to be part of that.”

The addition of Leah Jeffries further demonstrates UASI’s commitment to delivering results oriented mid-revenue cycle solutions and enhancing customer satisfaction across the healthcare landscape.

Inpatient Documentation and Coding Issues

Tue, 04 Mar 2025 18:27:10 GMT

UASI Analysis of the OIG Work Plan

Presented below is an analysis of new and ongoing initiatives under the Office of the Inspector General (OIG) Work Plan [1] and Centers for Medicare & Medicaid Services (CMS) approved Recovery Audit Contractor (RAC) reviews [2] as of January 2025. The focus is on inpatient initiatives related to HIM coding and documentation requirements and is not intended to review every active work plan item. For each relevant initiative, a summary of the compliance concern, the month and year of the initiative and related coding and documentation requirements is included. More importantly, for each inpatient initiative presented, UASI has included specific suggested compliance activities to assist our clients with their ongoing compliance efforts.

The Office of the Inspector General’s (OIG) work plan process is dynamic and changes are made throughout the year. This allows the OIG to meet priorities and react to emerging issues. The OIG work plan website is updated monthly. While there are many topics on the work plan, the majority do not apply to coding and documentation.

The information below includes an analysis of the following active inpatient topics:

· Medicaid Inpatient Hospital Claims with Severe Malnutrition (OIG)

· CMS Oversight of the Two-Midnight Rule for Inpatient Admissions (OIG)

· Inpatient Hospital MS - DRG Coding Validation (RAC)

Medicaid Inpatient Hospital Claims with Severe Malnutrition, Revised 2024

Severe Malnutrition remains an active item on the OIG workplan.

Malnutrition can result from treatment of another condition, inadequate treatment or neglect, or general deterioration of a patient’s health. Hospitals are allowed to bill for treatment of malnutrition based on the severity of the condition (mild, moderate, or severe) and whether it affects patient care. Severe malnutrition is classified as a major complication or comorbidity (MCC). Adding an MCC to a claim may result in higher reimbursement as the claim is coded to a higher MS-DRG.

Criteria related to severe malnutrition diagnosis and identification of severity is based on two main sets of criteria:

· First, the American Society of Parenteral and Enteral Nutrition (ASPEN).

o ASPEN criteria include three situations where malnutrition can occur, including:

§ 1) Acute illness/injury present for less than 3 months;

§ 2) Chronic illness present for 3 months or longer;

§ 3) Social and environmental circumstances limiting access or ability to self-care.

o In each of these situations, ASPEN criteria has specific measurement related to energy intake, weight loss, muscle mass loss, body fat loss, edema, and reduced grip strength.

· The second criteria in the Global Leadership Initiative on Malnutrition (GLIM).

o The GLIM criteria include three phenotypical criteria of weight loss, low BMI, and reduced muscle mass as well as two etiological criteria of reduced food intake or absorption, and increased disease burden or inflammation.

Documentation of severe malnutrition, as supported by either ASPEN and GLIM criteria, must also be supported by the treatment plan addressing the underlying etiology and continued treatment beyond the acute care setting.

UASI Suggested Compliance Activities

· Establish CDI and coding policies related to the use of either ASPEN or GLIM criteria in evaluating the documentation of malnutrition.

· Provider education

· Develop malnutrition education processes for providers with an emphasis on documentation of the appropriate malnutrition criteria.

· Provide ongoing and updated education as identified in documentation audits.

· Develop an audit plan

· Consider a second-level review process for evaluation of malnutrition documentation, prior to release of the claim.

· Establish an audit plan for concurrent and/or retrospective audits for a malnutrition diagnosis.

CMS Oversight of the Two-Midnight Rule for Inpatient Admissions, Revised 2024

Prior OIG audits identified millions of dollars in overpayments for inpatient claims with short lengths of stay. Instead of billing the stays as inpatient claims, they should have been billed as outpatient claims, which usually results in a lower payment. To reduce inpatient admission errors, CMS implemented the Two-Midnight Rule in fiscal year 2014. Under the Two-Midnight Rule, CMS generally considered it inappropriate to receive payment under the inpatient prospective payment system for stays not expected to span at least two midnights.

The only procedures excluded from the rule were newly initiated mechanical ventilation and any procedures appearing on the Inpatient Only List. Revisions were made to the Two-Midnight Rule after its implementation.

OIG plans to audit hospital inpatient claims after the implementation of and revisions to the Two-Midnight Rule to determine whether inpatient claims with short lengths of stay were incorrectly billed as inpatient and should have been billed as outpatient or outpatient with observation.

OIG also plans to review policies and procedures for enforcing the Two-Midnight Rule at the administrative level and contractor level. While OIG previously stated that it would not audit short stays after October 1, 2013, this serves as notification that the OIG will begin auditing short stay claims again, and when appropriate, recommend overpayment collections.

When a Medicare beneficiary arrives at a hospital in need of medical or surgical care, the physician or other qualified practitioner must decide whether to admit the beneficiary as an inpatient or treat him or her as an outpatient. These decisions have significant implications for hospital payment as not all care provided in a hospital setting is appropriate for inpatient services.

Beginning October 1, 2013, CMS adopted the Two-Midnight rule for admissions. This rule established Medicare payment policy regarding the benchmark criteria to use when determining whether inpatient admission is reasonable and necessary.

In general, the original Two-Midnight rule states:

· Inpatient admissions would generally be payable if the admitting practitioner expected the patient to require a hospital stay that crossed two midnights and the medical record supported that reasonable expectation. The rule was revised in 2016 to permit greater flexibility for determining when an admission that does not meet the benchmark should nonetheless be payable as an inpatient encounter.

· Medicare Part A payment is generally not appropriate for hospital stays expected to last less than two midnights.

· The documentation in the medical record must support that an inpatient admission is medically necessary.

The most recent update to the CMS Two-Midnight Rule occurred in April 2023, when CMS finalized the rule clarifying that Medicare Advantage (MA) plans must also adhere to the Two-Midnight Rule.

UASI Suggested Compliance Activities

· Collaborate with utilization review (UR) or case management (CM) for potential two- midnight rule issues

· If concurrent review processes are in place, review orders to ensure correct patient placement and involve UR as needed

Inpatient Hospital MS-DRG Coding Validation, February 2017

This topic remains on the UASI analysis as it is still an active RAC audit topic and there are ongoing audits related to MS-DRG Coding Validation. The background associated with this ongoing audit is noted below.

The OIG analyzed paid Medicare Part A claims for inpatient hospital stays from FY 2014 through FY 2019 and identified trends in hospital billing and Medicare payments for stays at the highest MS-DRG severity level. The number of stays at the highest severity level increased almost 20 percent from FY 2014 through FY 2019, ultimately accounting for nearly half of all Medicare spending on inpatient hospital stays. The number of stays billed at each of the other severity levels decreased. At the same time, the average length of stay decreased for stays at the highest severity level, while the average length of all stays remained largely the same. Specifically, nearly a third of these stays lasted a particularly short amount of time and over half of the stays billed at the highest severity level had only one diagnosis qualifying them for payment at that level. Shorter stays are not inherently problematic, but the number of these stays raises questions about the accuracy and appropriateness of the complications billed by the hospital. Although the complications billed suggest sicker beneficiaries, the shorter lengths of stay point to beneficiaries who are less sick. Excluded from this analysis are certain stays that could be expected to be shorter, such as stays during which the beneficiary died. Furthermore, over half of the stays billed at the highest severity level in FY 2019 (54%) reached that level because of just one diagnosis. In total, nearly 2 million stays had just 1 diagnosis (i.e., 1 major complication/comorbidity) that qualified the stay for the highest severity level. The rest of the submitted diagnoses for these stays were either minor complications or not complications.

As a result of this analysis, CMS continues to conduct targeted reviews of MS-DRGs and hospital stays that are vulnerable to up-coding (i.e., those that are billed at the highest severity level) and the hospitals that frequently bill for them. Specifically, CMS targets stays at the highest severity level with certain characteristics, such as those that are particularly short lengths of stay or that have only one major complication. CMS also focuses on MS-DRGs that have a high proportion of stays with these characteristics and on the hospitals that frequently bill them. CMS’s RACs currently conduct coding validation reviews that incorporate some of these targeting strategies. [7]

In evaluating current audit plans, consider focusing on short stays, especially those with a single CC or MCC or a complex principal diagnosis (e.g., Sepsis, AKI, ARF). UASI also suggests targeting some of the following MS-DRGs for audit depending on your case mix and volume:

· MS-DRGs 064 – 066 Intracranial Hemorrhage or Cerebral Infarction

· MS-DRGs 193 – 195 Simple Pneumonia and Pleurisy

· MS-DRGs 280 – 282 Acute MI Discharged Alive

· MS-DRGs 291 – 293 Heart Failure and Shock

· MS-DRGs 308 – 310 Cardiac Arrhythmias and Conduction Disorders

· MS-DRGs 377 – 379 Gastrointestinal Hemorrhage

· MS-DRGs 637 – 639 Diabetes

· MS-DRGs 689 – 690 Kidney & Urinary Tract Infections

· MS-DRGs 870 – 872 Septicemia or Severe Sepsis

· MS-DRGs 981 – 983 Extensive OR Procedures Unrelated to Principal Diagnosis

UASI Suggested Compliance Activities

· Select targeted MS-DRGs

· Evaluate the data for the top 20-25 MS-DRGs and review for any of the above indicators plus any additional MS-DRGs with high volume.

· Review the most recent PEPPER reports for MS-DRGs that may be at risk of improper payment. [8]

· Establish a prioritized list of MS-DRGs for review. If possible, review cases with short lengths of stay and one MCC/CC.

· Develop an audit plan

· Establish an audit plan for concurrent and/or retrospective audits.

· Retrospective audits can be conducted in part or wholly by incorporating selected MS-DRGs into your audit plan. Problem MS-DRGs can then be incorporated into a concurrent review work queue, if warranted.

· Concurrent coding audits should be limited in scope to address specific areas impacting quality reporting and reimbursement. Timeliness is critical as these accounts are held for additional review prior to releasing the bill. Turnaround time to release cases should be short, 24 to 48 hours, to minimize the impact to DNFB (discharged not final billed) daily/weekly goals.

· Audits can be conducted either internally or externally. Internal audits should be conducted based on the availability of staff with appropriate technical expertise (in coding and clinical documentation) and proficiency in communicating feedback through written reports and educational sessions.

· Determine the audit scope, considering opportunities for cross-departmental collaboration to address multiple risk factors. For example, clinical documentation improvement (CDI) staff may collaborate with coding staff to conduct an audit on sepsis DRGs, addressing both coding and clinical documentation compliance perspectives.

· At a minimum inpatient audit should measure and validate the following:

· Accurate identification of principal and secondary diagnosis and procedure codes in accordance with official and facility-specific coding guidelines

· Accurate MS-DRG or APR-DRG assignment

· Accurate POA indicator assigned for all non-exempt diagnosis codes

· Accurate Discharge Disposition assignment

· Develop corrective action plans, including physician and coder education, based on audit findings.

End Notes:

1. OIG Work Plan: https://oig.hhs.gov/reports-and-publications/workplan/index.asp

2. CMS, Approved RAC Topics, last revised 12/01/2024, accessed on January 14, 2025. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics

3. CMS Reminds Hospitals to Use Severe Malnutrition Codes Correctly. October 17, 2023. Article Detail - JF Part A - Noridian

4. Fact Sheet: Two-Midnight Rule; Oct 30, 2015. Fact Sheet: Two-Midnight Rule | CMS

UASI Compliance Analysis - Outpatient Documentation and Coding Issues

Thu, 13 Feb 2025 20:21:30 GMT

Outpatient Documentation and Coding Issues

Presented below is an analysis of new and ongoing initiatives under the Office of the Inspector General (OIG) Work Plan [1] and the Centers for Medicare & Medicaid Services (CMS) approved Recovery Audit Contractor (RAC) reviews [2] as of January 2025. The focus is on outpatient initiatives related to HIM coding and documentation requirements and is not intended to review every active work plan item. For each relevant initiative, a summary of the OIG or RAC compliance concern, the month and year published and added to the plan, and related coding and documentation requirements is included below. More importantly, for each outpatient initiative presented, UASI has included specific suggested compliance activities to assist our clients with their ongoing compliance efforts.

The information below includes an analysis of the following active outpatient topics:

· Medicare Payments for Lower Extremity Peripheral Vascular Procedures (OIG)

· Medicare Part C Audits of Documentation Supporting Specific Diagnosis Codes (OIG)

· Audits of Medicare Part C Health Risk Assessment Diagnosis Codes (OIG)

· Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (RAC)

· Transurethral Waterjet Ablation of the Prostate for Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms (LUTS) (RAC)

· Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (RAC)

Medicare Payments for Lower Extremity Peripheral Vascular Procedures, June 2024

Minimally invasive procedures aiming to improve blood flow when arteries narrow or become blocked because of peripheral arterial disease have been identified by CMS and whistleblower fraud investigations as vulnerable to improper payments. OIG will analyze Medicare fee-for-service for peripheral vascular procedures for questionable characteristics and review the program integrity activities of CMS and its contractors to combat fraud, waste, and abuse specific to these procedures. Additionally, these procedures will be assessed to ensure compliance with CMS requirements and meet applicable treatment guidelines.

Documentation should include:

· A description of the studies performed, and any contrast media and/or radiopharmaceuticals used

· Any patient adverse reactions and/or complications

· Normal and abnormal findings and comparison with prior relevant studies

· Variations from normal should be documented along with measurements.

· The report should address or answer any specific clinical questions.

· Results of all testing must be shared with the referring physician

· Adequate documentation to support medical necessity of performing non-invasive vascular studies

· medically necessary follow-up noninvasive vascular studies post-angioplasty is dictated by the vascular distribution treated

CMS expects that non-invasive vascular studies are not performed more than once a year.

A complete review of billing and coding requirements, including the CPT codes and an extensive list of ICD-10-CM codes that support medical necessity can be found at Article - Billing and Coding: Non-Invasive Peripheral Arterial Vascular Studies (A57593) (cms.gov)

Medicare Part C Audits of Documentation Supporting Specific Diagnosis Codes, November 2023

This is the first of two workplan items focusing on high-risk diagnoses that might result in inaccurate risk adjusted data. The first item focuses on quality of the documentation supporting the diagnoses and the second item: Nationwide Audits of Medicare Part C High-Risk Diagnosis Codes focuses on code accuracy,

Payments to Medicare Advantage (MA) organizations are risk-adjusted based on each enrollee's health. Inaccurate diagnoses may cause CMS to pay MA organizations improper amounts. In general, MA organizations receive higher payments for enrollees with more complex diagnoses. CMS estimates that 9.5 percent of payments to MA organizations are improper, mainly due to unsupported diagnoses submitted by MA organizations. Prior OIG reviews have shown that some diagnoses are more at risk than others to be unsupported by medical record documentation. We will perform a targeted review of these diagnoses and will review the medical record documentation to ensure that it supports the diagnoses that MA organizations submitted to CMS for use in CMS's risk score calculations and to determine whether the diagnoses submitted complied with Federal requirements.

Nationwide Audits of Medicare Part C High-Risk Diagnosis Codes, November 2023

Medicare Advantage (MA) organizations receive risk-adjusted reimbursement based on the health status of each enrollee. All MA organizations submit risk-adjustment data to CMS according to defined regulations. Mis-coded diagnoses can result in incorrect payments back to MA organizations. These audits will focus on identified high risk diagnoses being mis-coded and resulting in increased risk-adjusted payments from CMS. In a previous CMS audit of high-risk diagnoses, 183 of the 280 sampled enrollee-years, resulted in the following findings: 1) the medical record(s) provided did not support the diagnosis code(s) or 2) the medical record(s) could not be located; therefore, the diagnosis code(s) was not validated. [3]

Through data mining techniques and meetings with medical professionals, CMS identified diagnoses that are at a higher risk of being miscoded. These diagnoses include:

· Major depressive disorder: Concerns related to this diagnosis note that the diagnosis was documented but the patient did not have an antidepressant medication prescribed. As such, a major depressive disorder may not be supported in the documentation.

· Acute stroke: Findings for this diagnosis noted that an acute stroke diagnosis on a physician claim during a service year does not correspond to an inpatient or outpatient hospital claim.

· Vascular claudication: The vascular claudication findings noted a diagnosis during the service year which was not present during the preceding 2 years.

· Cancer: Findings related to several cancer diagnoses in this audit were related to a cancer diagnosis during the service year, however no treatment (e.g., surgery, radiation, or chemotherapy) was found within a 6-month period before or after the diagnosis. A diagnosis of history of cancer may be more appropriate. These cancer diagnoses include:

o Breast cancer

o Colon cancer

o Prostate cancer

o Lung cancer

· Acute myocardial infarction (AMI): These specific findings noted diagnoses of acute myocardial infarction on a physician or outpatient claim during the service year. However, there was not an AMI diagnosis on a corresponding hospital claim. A code for the history of MI may be more appropriate.

· Embolism: Enrollees received a diagnosis of acute or chronic embolism without an anticoagulant medication, which is typically used to treat an embolism. The history of embolism diagnosis may be more appropriate.

These findings confirm the CMS intention to continue auditing for and enforcing complete and accurate clinical documentation.

1. Improve population health data analytical capabilities and monitor high risk diagnosis reporting.

2. Utilize reports to determine the frequency of these high-risk diagnoses associated with risk-adjustment enrollees.

Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint, June 2023

Documentation will be reviewed to determine whether minimally invasive surgical fusion of the sacroiliac joint met Medicare coverage criteria and was reasonable and necessary. The only code included in this review is CPT code 27279, Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device. Additional procedure coding information can be found in the CPT Assistant, April 2023, Volume 33, Issue 4, page 16.

There are multiple different ICD-10-CM diagnosis codes that support the medical necessity for this procedure.

ICD-10-CM Diagnosis Code

Code Description

M43.27

Fusion of spin, lumbosacral region

M43.28

Fusion of spin, sacral and sacrococcygeal region

M46.1

Sacroiliitis, NEC

M51.17

Intervertebral disc disorders with radiculopathy, lumbosacral region

M53.2X7

Spinal instabilities, lumbosacral region

M53.2X8

Spinal instabilities, sacral and sacrococcygeal region

M53.3

Sacrococcygeal disorders, NEC

M533.87

Other specified dorsopathies, lumbosacral region

M53.88

Other specifies dorsopathies, sacral and sacrococcygeal region

M99.14

Subluxation complex (vertebral) of sacral region

S33.2XXA

Dislocation of sacroiliac and sacrococcygeal joint, initial encounter

S33.2XXD

Dislocation of sacroiliac and sacrococcygeal joint, subsequent encounter

S33.2XXS

Dislocation of sacroiliac and sacrococcygeal joint, sequela

S33.6XXA

Sprain of sacroiliac joint, initial encounter

S33.6XXD

Sprain of sacroiliac joint, subsequent encounter

S33.6XXS

Sprain of sacroiliac joint, sequela

S33.8XXA

Sprain of other parts of lumbar spine and pelvis, initial encounter

S33.8XXD

Sprain of other parts of lumbar spine and pelvis, subsequent encounter

S33.8XXS

Sprain of other parts of lumbar spine and pelvis, sequela

Coverage Indicators [4]

This procedure is considered medically necessary when ALL the following criteria are met:

· Have moderate to severe pain with functional impairment and pain persists despite a minimum six months of intensive nonoperative treatment that must include medication optimization, activity modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ, and hip including a home exercise program

· Patient’s report of typically unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized over the posterior SIIJ, and consistent with SIJ pain

· A thorough physical examination demonstrating localized tenderness with palpation over the sacral sulcus in the absence of tenderness of similar severity elsewhere and that other obvious sources for their pain do not exist

· Positive response to a cluster of 3 provocative tests

· Absence of generalized pain behavior

· Diagnostic imaging studies that include ALL the following

o Imaging (plain radiographs and a CT or MRI) of the SI joint that excludes the presence of destructive lesions, fracture, traumatic SIJ instability, or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion.

o Imaging of the pelvis (AP plain radiography

UASI Suggested Compliance Activity for this Initiative

1. Utilize reports to determine the frequency of CPT code 27279.

2. Based on these findings, determine the need to audit a percentage of the total cases.

Transurethral Waterjet Ablation of the Prostate for Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms (LUTS), April 2023

5 Ways to Reduce Revenue Leakage in 2025

brandon.uasi@gmail.com (Brandon Losacker) — Mon, 27 Jan 2025 20:17:42 GMT

5 Ways to Reduce Revenue Leakage in 2025

Taxpayers spend an average of $2.5 trillion overall for healthcare in the United States as the healthcare industry continues to face complex challenges in the coming year. While this is happening, providers feel the growing financial burden as tensions continue to rise between payers and providers. Understanding the current landscape will allow organizations, providers, and payers to proactively prepare their internal processes to meet industry needs and standards.

As a reference point, in January 2024, national health spending grew by 6.0% since January 2023 and represented 17.4% of GDP. Nominal GDP in January 2024 was 5.1% higher than in January 2023, growing more than 0.8 percentage points more slowly than health spending. The Health Research Institute (HRI) of Price Waterhouse Cooper recently predicted 2025 to have the highest medical cost trend in 13 years. HRI asserts that this trend is “driven by inflationary pressure, prescription drug spending and behavioral health utilization”. Even with the rising cost of healthcare, there is a decrease in overall revenue. What CFOs should be aware of is that this financial pressure will affect cash flow, reimbursement rates, and the ability to maintain margins.

Each day, we’ll be highlighting a critical area that mid-revenue cycle leaders should prioritize to prepare for these market shifts and reduce revenue leakage in 2025.

The 5 areas we’ll cover include:

#1 SDoH and Reimbursement Impact

#2 Tackling the Growing Threat of Claim Denials

#3 Avoid Costly Recoupments & Identify Missed Reimbursement Opportunities

#4 Harnessing Artificial Intelligence

#5 Reduce Penalties Through Accurate PSI Reporting

#1 Social Determinants of Health (SDoH) & Reimbursement Impact

The current focus on Social Determinants of Health (SDoH) will continue into 2025. The Inpatient Prospective Payment System (IPPS) final rule provided some good news related to SDoH. CMS plans to increase the federal standard rate by 2.9%. Part of this increase is a change in severity assignment for some SDoH codes. Specifically, treatment plans or encounters related to inadequate housing or housing instability will become a CC (Comorbidity Code) in 2025. The rationale for the changes in severity is due to the anticipated higher than average resource costs associated with these patients.

According to the U.S. Department of Health and Human Services, “In the FY 2024 IPPS final rule, CMS finalized a policy change to recognize the higher costs that hospitals incur when they provide hospital services for individuals experiencing homelessness. Building on this policy and the Biden-Harris Administration’s initiative to address unsheltered homelessness, CMS is taking an additional step to better account for the resources involved in furnishing care to individuals experiencing housing insecurity, meaning that hospitals will generally receive higher payments when a patient is experiencing housing insecurity.”

Healthcare leaders in the mid revenue cycle can reduce revenue leakage by focusing on accurate documentation and coding of SDoH. In particular, accurate documentation related to housing insecurity should be a critical focus as the 2025 IPPS changes will increase reimbursement rates for these patients. Accurate documentation of SDoH codes will not only improve reimbursement but also help address the higher resource costs associated with treating this patient population.

Read our recent article on SDoH to learn more! SDoH Can Make a Big Difference in Patient Care and Reimbursement

#2 Tackling the Growing Threat of Claim Denials

As we move into 2025, claim denials are expected to remain a significant challenge for healthcare providers and organizations. Denied claims disrupt cash flow, create additional administrative burdens, and can even impact the quality of patient care. According to a recent survey by Experian Health, 38% of healthcare professionals reported that one in every ten claims is denied, while 73% noted that denials rates are on the rise. This increase of denials is putting additional strain on already overburdened healthcare systems and making it harder for providers to maintain operational efficiency.

Most healthcare systems are struggling to address the growing volume of claim denials, and because of the administrative burden, fixing the root cause is often overlooked. With increasing claim volumes and complex payer requirements, healthcare providers are overwhelmed by the sheer number of denials in addition to the need to meet multiple deadlines for denials appeals. Compounding this challenge is the lack of specialized expertise in handling claim denials, which makes organizing the workflow and managing the appeals process difficult. Healthcare organizations that fail to address their claim denials are left vulnerable to revenue leakage through missed opportunities for reimbursement.

Conducting a denials program assessment is a necessary first step in understanding the root causes of denials and identifying areas for improvement. An assessment can help organizations gain insight into denials trends, develop targeted strategies to reduce denials, and identify ways to implement more efficient workflows. Additionally, an assessment can help identify where education and training are needed to improve accuracy and prevent denials altogether. Many systems find it difficult to even address all the denials as they come in, so they find it challenging to conduct an assessment. Partnering with a third-party authority can help with capacity to get an assessment completed but also provide an objective perspective. In addition, an outsource partner and/or implementing A.I. can help alleviate the burden and cover more volume. An assessment can help identify the best options to solve the problem.

#3 Avoid Costly Recoupments & Identify Missed Reimbursement Opportunities

In 2024, the Office of Inspector General (OIG) identified several areas in healthcare billing that could cost the American taxpayers billions of dollars in recoupments. To note, the OIG conducts audits to ensure that healthcare claims are compliant with federal regulations. For example, one of the significant findings from the OIG in 2024 was noncompliance with the “two-midnight rule”, which requires a patient’s hospital stay to span two midnights to qualify for inpatient payment.

In 2025, OIG audits are expected to continue focusing heavily on validating claims data, ensuring accurate code assignment, and confirming that clinical documentation supports medical necessity. Healthcare systems must prepare for increased scrutiny of their claim’s data.

Without a process in place to identify discrepancies in documentation early on, healthcare providers risk triggering unnecessary OIG audits, which could result in costly recoupments. Often, third-party audits are conducted too late once discrepancies have already led to compliance issues and financial loss. This reactionary approach can be avoided by completing preemptive reviews and audits before an official OIG audit occurs.

To stay ahead, healthcare organizations must shift their mindset from a reactive to a proactive approach. By conducting regular, ongoing audits or reviews, providers can identify risks and address pitfalls before they escalate into major compliance issues. Furthermore, healthcare systems who elect to conduct proactive 3rd party audits, should view them not merely as a tactic to avoid OIG audits, but as a larger, strategic move to boost ROI by ensuring accurate coding and reimbursement opportunities. Preliminary audits arm healthcare systems with the information and resources to comply with federal regulations while discovering opportunities for increased revenue.

#4 Harnessing Artificial Intelligence

In utilizing vast amounts of data, A.I. can be harnessed to increase productivity. With these advancements and their impact on the revenue cycle, it is leaving industry experts wondering how the function of accurate code assignment will look in the future. In addition, for smaller healthcare organizations with lower patient volumes, the adoption of A.I. may seem out of reach. This leaves many leaders in the mid revenue cycle uncertain about how to begin integrating these technologies into their operations.

As the technology develops and improves, A.I. has the potential to reduce administrative burdens and address the complexity of billing and coding accuracy while improving patient care. These potential improvements could impact the financial health and sustainability of hospitals and physician groups nationwide. To combat healthcare’s rising costs, increase in payer denials, and the need for accurate code assignment, the integration of AI into the revenue cycle will likely become a key competitive differentiator for healthcare organizations in 2025.

While the integration of A.I. in CC (Code Capture) has become more widespread, the technology often requires significant volume, so many smaller healthcare facilities have yet to benefit. In addition, the more complex aspects of coding still require human oversight and expertise. The challenge that many health systems face is in regard to identifying the right tool and how to begin integrating new tools into an already established workflow. Partnering with firms that can assist in evaluating AI tool options, help healthcare facilities manage the people processes, and develop the roadmap associated with these new technologies to ensure ROI, is worth consideration. Short term spend for long-term benefits.

#5 Reduce Penalties Through Accurate PSI Reporting

Patient Safety Indicators (PSIs) are a set of measurement tools developed by the Centers for Medicare and Medicaid Services (CMS) to track adverse patient outcomes, such as hospital-acquired infections, falls, and other complications. These indicators are used to assess the quality of care provided by hospitals and highlight areas where patient safety can improve. Hospitals are required to report PSIs to CMS as part of their participation in Medicare and Value-Based Care programs.

PSIs directly impact revenue through penalties and reduced reimbursements. Hospitals with high rates of hospital-acquired conditions are penalized with lower reimbursements, particularly if they rank in the bottom 25% of PSI 90 scores. Despite improvements in PSI reporting, CMS consistently penalizes the lowest performing facilities. In addition, as the healthcare industry continues shifting to Value Based Care (VBC), a portion of Medicare reimbursements will continue to be tied to PSIs making accurate PSI reporting more crucial than ever. It bears mentioning that public PSI data can also harm a hospital's reputation, leading to reduced patient volume and further revenue loss.

To reduce revenue leakage caused by inaccurate PSI reporting, healthcare systems must focus on improving the accuracy of their documentation and coding. Many reported PSIs can be avoided if accurately documented, especially by drawing on the knowledge of Clinical Documentation Integrity (CDI) and Quality experts. For example, establishing accurate present on admission (POA) status through simple queries can remove patients from specific PSI categories. In addition, understanding the specific exclusion diagnoses for PSIs, like those related to elective surgeries, can prevent inaccurate PSI reporting.

Want to learn more about Patient Safety Indicators? Read our lates article on PSIs to learn more:

Patient Safety Indicators: Aligning CDI and Coding with Quality Goals

A look at “Z” Codes and the importance of their capture

brandon.uasi@gmail.com (Brandon Losacker) — Mon, 27 Jan 2025 20:17:40 GMT

Z Codes in ICD-10-CM: Clinical Impact, CC Status, and Coding Guidance

Overview of Z Codes and Their Role in ICD-10-CM

What Are Z Codes?

Z Codes: Z00-Z99, Factors influencing health status and contact with health services
This category of codes captures those circumstances that do not fall into disease, injury or external cause that classify into categories A00-Y89.

Clinical Impact of Z Codes and CC Classification

Several Z codes will classify as a CC and represent circumstances that can impact medical decision-making, complexity, hospital resources, and length of stay. (e.g., antimicrobial resistance, SDOH, BMI, and transplant status)

Let’s look at a few of these codes and dig into their clinical impact for patients and the providers managing their care. Individual codes were selected to demonstrate all the considerations of care for a single condition. The other codes would demonstrate a very similar picture. Click on the link to see the entire list of “Z” codes that classify as a CC at the end of this tip.

Z16.12: Antimicrobial Resistance and ESBL Coding Considerations

Z16.12, Extended spectrum beta-lactamase (ESBL) resistance (Classifies as a CC)

ESBLs are enzymes that destroy the beta-lactam ring in most beta-lactam antibiotics that include penicillins, cephalosporins, and the monobactam class antibiotic, aztreonam. They are associated with poor outcomes for patients with these infections.

Confirmatory testing for the presence of ESBLs can be difficult as their structural makeup is not uniform. All ESBLs do not respond to the same antimicrobial agents.

Rates for ESBL have increased from 11.1 infections per 100,000 patient days to 22.1 between 2009-2014. Rates in children have also increased from 0.28% in 1999-2001 to 0.92% in 2010-2011.

Provider choice of antibiotics is crucial for clinical response and risk of mortality. A study shows that failure to treat appropriately in the first 5 days after culture result is associated with a 64% mortality rate versus 14% with an ESBL-sensitive choice.

ESBL infections are associated with higher mortality rates, longer hospital stays, greater hospital expenses, and reduced rate of clinical response to treatment than similar gram-negative bacteria that do not produce ESBL.

Z59 Codes: Homelessness and Social Determinants of Health

Z59.00, Homelessness, unspecified; Z59.01, Sheltered Homelessness; Z59.02, Unsheltered homelessness (All classify as CCs)

Chronic homelessness is defined as, “an individual with a disabling condition who has been either continuously homeless for at least one year or homeless at least four times in the past three years” according to the US Department of Housing and Urban Development.

Mortality rates among youth and young adults are 8-11-fold higher than the non-homeless population. Rates are also high for the unsheltered homeless population.

Those experiencing homelessness have high rates of hospitalization and ER use compounded by poor access to primary care and many basic health services.

There are several specific health conditions for the homeless population. These include skin and foot problems, respiratory infections, and issues with dentition. Conditions that are more comparable with the general population are often more poorly controlled.

Patients that are experiencing homelessness present unique health risks and social challenges. Discharge planning can be a hurdle and hospital social service staff are critical.

Z94.81: Bone Marrow Transplant Status and Clinical Risk

Z94.81, Bone marrow transplant status (Classifies as a CC)

A procedure in which defective or cancerous bone marrow is replaced with healthy, new bone marrow cells. This helps with treatment of leukemia, lymphoma, sickle cell anemia, and multiple sclerosis. They may be autologous or allogenic.

Patients are subject to numerous complications such as multi-organ effects, bleeding risk, mucositis, liver dysfunction, infections, and neuropsychiatric conditions.

Those patients that are admitted to the ICU have higher rates of associated mortality.

Development of any of these conditions may influence the quality of life, duration of hospitalization, longer-term complications, and outcomes from transplantation.

Importance of Z Codes in Capturing the Full Clinical Picture

Although “Z” codes may not get the attention that other codes may get in the inpatient setting, they are important to capture the entire clinical picture for certain patient populations. The examples used in this tip are all codes that risk adjust in certain methodologies as well.

Works Cited

Baggett, T. (2023). Healthcare of people experiencing homelessness in the United States. UpToDate. Available at: https://www.uptodate.com/contents/health-care-of-people-experiencing-homelessness-in-the-united-states

Hooper, D. (2024). Extended-spectrum beta-lactamases. UpToDate. Available at: https://www.uptodate.com/contents/extended-spectrum-beta-lactamases

MD Anderson Cancer Center . (2025). Stem cell (bone marrow) transplants. Available at: https://www.mdanderson.org

Negrin, R. (2024). Early complications of hematopoietic cell transplantation. UpToDate. Available at: https://www.uptodate.com/contents/early-complications-of-hematopoietic-cell-transplantation

Pinson, R., & Tang, C. (2024). The CDI Pocket Guide. CDI Plus. Available at: https://www.cdiplus.com

How to Prepare for Major Healthcare Policy Changes: A Guide for Revenue Cycle Leaders

brandon.uasi@gmail.com (Brandon Losacker) — Thu, 23 Jan 2025 20:31:37 GMT

Navigating the complexities of healthcare reform requires a proactive approach. As the landscape continues to evolve, revenue cycle leaders must prepare for upcoming policy changes while mitigating potential financial risks. At UASI, we focus on equipping providers with strategies to manage these challenges effectively and ensure long-term success.

Here are four critical areas of change and how to prepare:

1. The Expiration of ACA Subsidies

Enhanced subsidies under the Affordable Care Act (ACA) are set to expire at the end of 2025. If Congress does not extend these subsidies, premiums for many enrollees could surge by more than 75%, leading to a significant rise in uninsured patients. For healthcare organizations, this could mean a decrease in commercially insured patients and an increase in Medicaid or uninsured populations, driving up uncompensated care and bad debt .

Steps to Prepare:

Identify Revenue Impact: Conduct financial modeling to assess the potential impact of payer mix shifts on your revenue.
Optimize Medicaid Processes: Strengthen Medicaid eligibility and enrollment workflows to reduce gaps in reimbursement.
Enhance Financial Counseling: Train staff to assist patients in exploring available insurance options and payment plans.

By proactively addressing these areas, organizations can minimize revenue leakage and maintain financial stability.

2. Potential Changes to Medicare’s Inpatient Only List

Efforts to phase out Medicare’s Inpatient Only (IPO) list have been a contentious topic. While earlier attempts to eliminate the list were reversed, a renewed focus on reducing covered inpatient procedures is possible. Hospitals may face increased pressure to justify inpatient admissions to ensure proper reimbursement.

Steps to Prepare:

Review Care Protocols: Ensure inpatient admissions align with Medicare guidelines by conducting regular audits.
Strengthen Documentation: Partner with CDI experts to bolster clinical documentation supporting medical necessity.
Develop Training Programs: Educate care teams on evolving regulations and documentation best practices.

These measures will help organizations navigate the transition while securing appropriate reimbursements.

3. Medicare Advantage Expansion

The growth of Medicare Advantage plans continues to raise concerns for providers. These plans often deny claims at twice the rate of commercial insurance , adding administrative burdens that strain resources. Any expansion of these plans could significantly affect hospital cash flow and operational efficiency.

Steps to Prepare:

Conduct a Denials Assessment: Identify root causes of denials and implement corrective action plans.
Automate Claims Processes: Leverage technology to streamline workflows and improve claims accuracy.
Partner with Experts: Collaborate with a third-party partner like UASI to manage denials efficiently and reduce administrative strain.

By taking these steps, healthcare organizations can mitigate the impact of Medicare Advantage expansion on revenue cycles.

4. The Rise of Site-Neutral Payment Policies

Site-neutral payment policies—requiring Medicare to reimburse services equally across care settings—pose another potential challenge. While aimed at cost savings, these policies often overlook the higher operating costs of hospitals, which provide 24/7 care and meet rigorous regulatory requirements. A mid-sized health system, for example, could lose upwards of $5 million annually under expanded site-neutral rules.

Steps to Prepare:

Analyze Service Lines: Evaluate which services are most vulnerable to site-neutral payment changes and adjust strategies accordingly.
Advocate for Fair Reimbursement: Join industry groups to advocate for policies that reflect the higher costs of hospital-based care.
Diversify Revenue Streams: Explore alternative revenue opportunities, such as outpatient services and partnerships.

Preparing for these changes will position providers to adapt to regulatory shifts and safeguard financial health.

Leveraging Industry Insights for Better Outcomes

Industry trends highlight the critical importance of reducing revenue leakage through proactive strategies. These include improving documentation accuracy, conducting denial program assessments, and leveraging innovative technologies like AI. By aligning your organization with these approaches, you can address common challenges such as rising denial rates, compliance risks, and inefficiencies in revenue cycle management.

UASI’s expertise supports these priorities by helping providers strengthen their financial and operational performance. Whether it’s addressing the impact of payer mix changes, improving claims accuracy, or mitigating regulatory risks, our tailored solutions empower organizations to navigate an increasingly complex healthcare environment.

UASI remains a trusted partner through change and uncertainty, offering the expertise and support needed to navigate these challenges while driving financial and operational success for healthcare organizations.

References:

ACA Subsidies Impact: https://www.kff.org/interactive/how-much-more-would-people-pay-in-premiums-if-the-acas-enhanced-subsidies-expired/
Medicare Inpatient Only List Updates: https://www.findacode.com/newsletters/aha-coding-clinic/hcpcs/cy2024-changes-medicares-inpatient-list-H241004.html
Medicare Advantage Expansion Concerns: https://jamanetwork.com/journals/jama-health-forum/fullarticle/2815743
Site-Neutral Payment Policy Analysis: https://www.aha.org/fact-sheets/2023-03-21-fact-sheet-medicare-hospital-outpatient-site-neutral-payment-policies

New for 2025: HCC Passport Now Available!

brandon.uasi@gmail.com (Brandon Losacker) — Thu, 23 Jan 2025 14:14:29 GMT

At UASI Outpatient CDI Solutions, we combine deep clinical expertise and coding precision to help you navigate the complexities of HCC capture in real time.

We’re excited to announce the release of our 2025 HCC Passport!

The updated version offers over 35 pages of critical documentation tips, all derived from UASI outpatient audit findings across the country. This comprehensive guide is packed with actionable insights to help healthcare providers:

✅ Capture the specificity of diagnoses

✅ Improve quality metrics

✅ Identify chronic conditions for accurate HCC coding

✅ Ensure accurate reporting of procedures

At UASI Outpatient CDI Solutions, we combine deep clinical expertise and coding precision to help you navigate the complexities of HCC capture in real time.

Ready to level up?

Pressure Ulcer ICD-10-CM Coding and HCC Mapping

Tue, 14 Jan 2025 18:34:28 GMT

Outpatient CDI for Pressure Ulcers and Chronic Skin Ulcers: ICD-10-CM Coding and HCC Guidance

Pressure ulcers are localized damage to the skin and/or soft tissue caused by prolonged pressure, often associated with immobility and/or lack of sensation. Contributing factors can include moisture and nutritional deficiencies.

Diagnostic Criteria and Staging of Pressure Injuries

Stages and Definitions (NPIAP):

Stage 2: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may present as an intact or ruptured serum-filled blister.
Stage 3: Full-thickness skin loss. Adipose tissue is visible in the ulcer, with granulation tissue and epibole (rolled wound edges) often present. Slough and/or eschar may be visible.
Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Slough and/or eschar may be present.
Unstageable: Obscured full-thickness skin and tissue loss where the extent of tissue damage cannot be confirmed due to slough or eschar. Removal may reveal a Stage 3 or Stage 4 injury.

Treatment Approaches for Pressure Ulcers

Wound care/dressings, debridement, wound care referral, hyperbaric oxygen therapy
Pain management, antibiotics, topical treatments
Advanced stage treatment may include necrotic tissue excision, wet-to-dry saline or hypochlorite solution dressings, topical antibiotics, or specialized gels

Background and Terminology Updates

The term "pressure ulcer" is outdated. The National Pressure Ulcer Advisory Panel (NPIAP), founded in 1987, changed its terminology to "pressure injury" in 2016 and updated its name in 2019. A pressure injury is now defined as localized skin and soft tissue damage typically found over a bony prominence or caused by medical devices.

Statistics on pressure injuries are limited. The 1999 Fifth National Pressure Prevalence Survey reported a 14.8% prevalence in acute care hospitals, with 7.1% occurring during hospital stays.

Increased Risk Factors: Neurologic disease, cardiovascular disease, prolonged anesthesia, dehydration, malnutrition, hypotension, and surgery.

ICD-10-CM Codes and HCC Mapping for Pressure Ulcers

ICD-10 Codes and HCC Mapping:

HCC 379: Community, Non-Dual, Aged - 1.965
HCC 381: Community, Non-Dual, Aged - 1.075
HCC 382: Community, Non-Dual, Aged - 0.838

Coding and CDI Tips for Pressure Ulcers and Skin Ulcers

Document the pressure ulcer's location and its stage
Note treatment and any complications related to the ulcer
Indicate if there was a referral to wound care
Clarify that pressure injuries are coded as pressure ulcers
Differentiate pressure ulcers from moisture-associated skin damage (MASD)
Specify ulcer stage, including unstageable ulcers, to ensure accurate HCC assignment
For ulcers described as "healing," assign the code for the current stage. If "healed," no code is necessary
Distinguish between pressure and chronic non-pressure ulcers , which map to different HCCs (380, 383)

Query Example for Pressure Ulcer Documentation

Visit note from [date] indicates the presence of a pressure ulcer on the right heel. The stage is not documented. Exam on [date] describes full-thickness ulceration into subcutaneous soft tissue.

Please specify the stage of the pressure ulcer:

Stage 2
Other stage (please specify)

Works Cited

Centers for Medicare & Medicaid Services. (2023). Announcement of Calendar Year (CY) 2024 Medicare Advantage Capitation Rates and Part C and Part D Payment Policies. Available at: https://www.cms.gov/files/document/2024-announcement-pdf.pdf

Edsberg, L. E., et al. (2016). Revised National Pressure Ulcer Advisory Panel pressure injury staging system. Journal of Wound, Ostomy and Continence Nursing, 43(6), 585–597. Available at: https://doi.org/10.1097/WON.0000000000000281

Pinson, R., & Tang, C. (2024). CDI Pocket Guide. CDI Plus.

Zaidi, S. R. H., & Sharma, S. (2024). Pressure ulcer. StatPearls Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK553107/

Advancing Global Health Using Digital Technologies

Wed, 18 Dec 2024 20:30:45 GMT

Artificial Intelligence in Healthcare: Compliance, Risk, and Responsible Use

“Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence”

On December 4, 2024, Title 42 of the Medicare Advantage plan was amended by CMS and the goal was to implement reforms that will ultimately improve healthcare access, quality, and equity for Medicare beneficiaries. This change is related to executive order 14110 by the Biden-Harris Administration, “Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence” which ensures that the development of AI does not jeopardize the advancement of equity and civil rights especially in health organizations. Institutions that do not comply with this amendment will be subjected to possible prosecution.

Artificial Intelligence (AI) is rapidly becoming a prominent force in our society, and its application in healthcare is viewed with both hope and caution. Health information professionals must understand what AI entails, its capabilities, and how to employ it responsibly and ethically. With increased use of AI in healthcare, questions arise about maintaining patient trust and safeguarding data integrity, especially given the discrepancies and accuracy rate of AI-driven data collection and analysis. Additionally, with the increasing automation of revenue cycle operations in healthcare systems, ensuring coding accuracy, billing, and documentation in this evolving landscape becomes even more crucial.

Global Perspectives on AI and Digital Health in Healthcare: AHIMA and GDHP Partner for First Health Information Summit

In November AHIMA and IFHIMA joined forces and conducted the first global policy summit of health information professionals and presented on public issues related to the health information profession in collaboration with GDHP (Global Digital Health Partnership), a collection of national digital health authorities and the World Health Organization (WHO).

In short, digital health is the “systematic application of information and communications technologies, computer science, and data to support informed decision-making by individuals, the health workforce, and health institutions, for strengthened resilience and improved health and wellness for all.” Digital health includes digital technology-based data fields e.g., data analytics, artificial intelligence, eHealth, and telemedicine, to name a few.

A central concern of the summit was the evolving impact of digital health technologies, in particular the implementation of AI, and the priorities and needs of professionals within the health information sector as they relate to digital health. During the summit, key policies were discussed that are currently impacting the health information profession.

Federal Guidance and Recommended Practices for Digital Health: UASAID Recommended Practices

In addition to the global policy health summit, the United States Agency for International Development (USAID) recently released a position paper titled Digital Health which outlined four priorities for programmatic digital health investments. These focal areas underscore the federal government’s strategic emphasis on advancing digital health technologies. These priorities range from strengthening a country’s digital health environment to aligning digital health investments with national architecture. Additional recommended practices outlined by USAID include:

Requiring standards to enable integrated health care service delivery at scale.
Establishing standards that equate to better coordination of care, and deepening engagement with local partners.
Engaging with local partners including the private sector to support the ability of global health funders like USAID to be effective long-term partners to government ministries of health.

Preparing HIM and Revenue Cycle Teams for AI Adoption

CFO’s and Directors of HIM need to ensure compliance with CMS regulations while preparing for stricter federal-level oversight in addition to monitoring the overall performance of AI solutions. The need for education and training will continue to grow to accurately assess AI-driven data, ensuring that decision-making remains informed and aligned with regulatory standards.

UASI collaborates with healthcare systems to enhance workforce capabilities in exchanging and using relevant healthcare data by reviewing and identify coding and documentation errors that impact revenue integrity and patient care, ensuring the accuracy and integrity of patient information. UASI is committed to supporting the digital transformation of health systems with long-term vision of achieving data interoperability, ensuring equity in the use of AI, and creating globally sustainable health systems.

Works Cited:

World Health Organization. (2021). Ethics and governance of artificial intelligence for health. Available at: who.int/publications/i/item/9789240029200

Executive Office of the President. (2023). Executive Order 14110—Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence. Available at: govinfo.gov/content/pkg/DCPD-202300949/html/DCPD-202300949.htm

Challenges of Risk Adjustment in Value Based Care; Insights from Industry Leaders

brandon.uasi@gmail.com (Brandon Losacker) — Wed, 18 Dec 2024 20:30:20 GMT

Value-based care (VBC) models are continuing to gain traction to improve care outcomes while controlling costs. However, the transition to VBC comes with its own set of challenges, specifically around risk adjustment, which is vital to ensuring accurate reimbursement. To better understand these hurdles, UASI asked industry leaders for their insights into the complexities of implementing and managing Risk Adjustment in VBC models.

Key Challenges in Adopting VBC Models

Industry leaders in healthcare highlighted several challenges related to adopting Value-Based Care models and identified several barriers;

Staff resistance to new care delivery and reimbursement models, and a lack of education and training hinders understanding and adoption of VBC. Aligning processes and workflows with new care models can disrupt established practices, while difficulties in aligning with payor contracts, due to varying quality metrics and reimbursement formulas, create further obstacles. Additionally, many healthcare systems face inadequate operational capacity and a shortage of a specialized workforce , making it difficult to scale VBC models effectively.

Resources for VBC Implementation and Optimization

To effectively manage value-based care (VBC) models , industry leaders weighed in and identified several key resources to better support VBC implementation. Those organizations with more mature programs have 6 key components in place in managing a successful program:

The main needs identified were data analytics to track patient outcomes and costs
Comprehensive training and education programs to equip staff with the knowledge to effectively implement VBC.
Leaders in Risk Adjustment would like to see a defined strategy and objectives within their organizations to guide decision-making
The tools and technology to support the strategy.
Financial incentives from payors are needed such as quality measures and shared savings programs to leverage more support for VBC implementation.
Regulatory guidance can also help health systems to navigate VBC complexities and ensure compliance.

Challenges in Data Accuracy and Metrics for Evaluating Success

Data accessibility and accuracy are major barriers within Risk Adjustment. Ensuring that data is comprehensive and accurate is needed for calculating risk scores and understanding where to focus efforts. With multiple risk adjustment models in place, organizations struggle to find processes that create efficiencies. Additionally, provider burnout and workflow management issues arise as providers navigate various VBC models.

To ensure effectiveness, there are a set of metrics to evaluate Risk adjustment and value-based care models:

Hospital Readmission Rates : Reducing hospital readmissions indicates the success of preventive care and is a goal of VBC.

· Mortality Rates : Mortality rates focus on the overall quality of care and patient outcomes.

Cost per Patient per Month (PMPM) and Total Cost of Care : Tracking the cost per patient is essential to managing the financial aspects of VBC, ensuring that the system remains financially viable while improving care quality. Total cost of care is a broad metric that captures the financial efficiency of the care model.

Shared Savings Revenue : This metric tracks the financial savings generated through VBC initiatives, which are shared between providers and payors.

Quality Scores (HEDIS, STAR Ratings) : National quality measures such as HEDIS and STAR ratings provide objective benchmarks for evaluating the effectiveness of care delivery.

Risk Adjustment Accuracy Scores (RAF, Recapture Rate) : These scores are essential for evaluating the precision of risk adjustment models. RAF is the estimated yearly cost to treat a patient whereas the Recapture Rate refers to how well a provider captures recurring HCC diagnoses and is also used to understand future healthcare costs.

Suggestions for Improvement

Improvements must be organizational and system wide as industry leaders highlight that viewing Risk Adjustment and VBC as just a revenue cycle or coding issues is a major barrier. Instead, these challenges require an integrated approach involving clinicians, administrators, and payors to drive the necessary changes . As previously stated, healthcare organizations face challenges like staff resistance, workflow management, and data accessibility/accuracy. However, with the right resources these obstacles can be overcome.

Let UASI help you bridge the gap by assessing your Risk Adjustment practices, identify gaps, and develop targeted solutions.

CDI Tip on Obesity

brandon.uasi@gmail.com (Brandon Losacker) — Wed, 11 Dec 2024 15:23:00 GMT

Obesity: Understanding the Condition and Its Implications

Definition:

• Obesity: A state of excess storage of body fat.

• Overweight: Refers to excess body weight for height.

Facts and Statistics: The Centers for Disease Control (CDC) reported in August 2024 that more than 100 million U.S. adults aged 20 or older have obesity, with 22 million classified as severely obese. Additionally, 14.7 million cases of obesity have been reported in U.S. children and adolescents aged 2-19. The National Center for Health Statistics shows that the obesity prevalence in adults (aged 20 and older) rose from 19.4% in 1997 to 31.4% by the reporting period of January-September 2017.

Diagnostic Criteria:

• Underweight: BMI < 18.5 kg/m²

• Normal Weight: BMI 18.5–24.9 kg/m²

• Overweight: BMI 25–29.9 kg/m²

• Obesity (Class 1): BMI 30–34.9 kg/m²

• Obesity (Class 2): BMI 35–39.9 kg/m²

• Extreme Obesity (Class 3): BMI > 40 kg/m²

Note: Morbid obesity is defined by a BMI > 40 kg/m², or a BMI of 35 or higher with at least one weight-related comorbidity, such as diabetes, heart disease, stroke, hypertension, or arthritis.

Diagnostic Tests:

• Fasting Lipid Panel

• Liver Function Studies

• Thyroid Function Tests

• Fasting Glucose and Hemoglobin A1c (HbA1c)

Treatment:

• Nutritional consult

• Counseling on diet and exercise

• Medications such as GLP-1s

• Bariatric surgery procedures

• Treatment for associated comorbid conditions

________________________________________

Coding and CDI Considerations:

• Overweight and obesity codes are found in category E66. An instructional note directs the reporting of BMI, if known, as an additional diagnosis (adults: Z68.1-Z68.45; pediatrics: Z68.5-).

• Code E66.01 classifies morbid (severe) obesity due to excess calories. Documentation of "severe" obesity allows the assignment of this code. However, E66.01 has an Excludes1 note that it should not be coded with E66.2, which refers to morbid obesity with alveolar hypoventilation.

• BMI codes can be taken from non-physician documentation, but the physician must provide an associated diagnosis.

IPPS FY 2025 New Codes for Obesity:

• E66.811 Obesity, Class 1

• E66.812 Obesity, Class 2

• E66.813 Obesity, Class 3 (synonymous with morbid obesity)

• E66.89 Other obesity, not elsewhere classified

Current coding guidance states that obesity and morbid obesity are always clinically significant and should be reported when documented. No additional documentation is required to support clinical significance for this condition (such as evaluation, treatment, or increased monitoring).

Obesity and Comorbid Conditions:

CDI specialists should review for obesity-related comorbid conditions, such as:

• Obstructive sleep apnea (OSA)

• Malignancy

• Coronary artery disease (CAD)

• Hypertension (HTN)

• Gallbladder disease

• Osteoarthritis

• Diabetes

• Stroke

• Depression

If the patient's BMI is 35 or higher and they have a comorbid condition related to obesity, this may be considered morbid obesity. The provider should document the relationship between weight and the comorbid condition to demonstrate the need for specific management and strengthen medical necessity and decision-making. Obesity also impacts risk adjustment methodologies, including Elixhauser and AHRQ PSIs.

Query Example:

Please specify if the condition you are managing can be represented as:

• Morbid Obesity

• Obesity, Class 2

• Other condition (please specify)

The following clinical indicators are noted in documentation:

• RN admission assessment with BMI 38.5

• Nutrition consult ordered

• Chronic conditions of Type II Diabetes and Hypertension

References:

• AHA Coding Clinic 2018 Fourth Quarter, p. 77

• Hamdy, O. (2024). Obesity. Medscape. www.medscape.com

• Official Coding Guidelines Sections I.C.19.a and I.C.19.c

• Pinson, R., Tang, C. (2024). Body Mass Index and Obesity. CDI Pocket Guide. CDIPlus

• Prescott, L., Manz, (2024). Morbid Obesity. ACDIS Pro

• US Centers for Disease Control and Prevention. New CDC Data Show Adult Obesity Prevalence Remains High. CDC. Available at https://www.cdc.gov/media/releases/2024/p0912-adult-obesity.html . September 12, 2024; Accessed: November 26, 2024.

Telehealth Coding Tip

brandon.uasi@gmail.com (Brandon Losacker) — Wed, 11 Dec 2024 15:10:11 GMT

For FY 2025 CPT has deleted the following audio only codes.

99441 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment: 5-10 minutes of medical discussion

99442 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment: 11-20 minutes of medical discussion

99443 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment: 21-30 minutes of medical discussion

CPT has created 16 new telehealth codes (98000-98016). But at this time per the Federal Register to be published on 12/9/2024 Medicare does not plan to recognize these codes. CMS plans to assign payment status code “I” ) Not valid for Medicare purposes) to these codes. 1

Therefore, for evaluation and management (E/M) visits performed over telehealth, you’ll continue to use the existing E/M codes, such as 99202- 99215 for Medicare payers. It’s unclear which private payers – if any- do plan to recognize 98000-98016 in 2025.

**Most insurers will be issuing their 2025 coverage guidelines in coming weeks. 2

1. Federal Register :: Public Inspection: Medicare and Medicaid Programs: Calendar Year 2025 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Prescription Drug Inflation Rebate Program; Medicare Overpayments

2. 2025 Medicare Fee Schedule Targets Telehealth, Advanced Primary Care Management

Understanding Critical Illness Myopathy (CIM) and Related Conditions

brandon.uasi@gmail.com (Brandon Losacker) — Tue, 03 Dec 2024 20:29:57 GMT

Critical Illness Myopathy (CIM):
Describes a rapidly evolving primary myopathy with generalized muscle wasting due to prolonged immobilization.

Characterized by more proximal than distal weakness, sensory preservation, and atrophy depending on the duration of illness.
Usually occurs in the intensive care setting.
Providers may also refer to this as acquired care weakness when no specific etiology is identified.

Critical Illness Polyneuropathy (CIP):
Exhibits both sensory and motor manifestations, determined by physical exam and electrodiagnostic study.

Characterized by more distal than proximal weakness, sensory changes, and limited atrophy.

Critical Illness Polyneuromyopathy (CIPNM):
Describes a combined myopathy with characteristics of both CIM and CIP.

Characterized by a combination of proximal greater than distal weakness, distal sensory loss, and variable atrophy.
Clinically, CIM and CIP manifest as limb and respiratory muscle weakness.

Risk Factors for CIM

Prolonged intubation/failure to wean
Gram-negative bacteremia, hyperglycemia, hyperpyrexia, hyperosmolarity, hypoalbuminemia, hypoxia, hypotension, hyper/hypocalcemia
Advanced age or female sex
Sepsis, ARDS, COVID-19, asthma, organ transplant patients
Use of steroids and/or non-depolarizing neuromuscular blockades (atracurium besylate, vecuronium bromide, pancuronium bromide)

Diagnostic Criteria

Electrodiagnostic studies: Nerve conduction studies, electromyography, and direct muscle stimulation
Past medical history evaluation
Clinical exam
Medical Research Council (MRC) sum score: Used as an initial diagnostic measure of muscle strength in conscious patients (CIP and CIM are thought to be present if the score is less than 48)
Diagnostic labs to rule out other conditions contributing to weakness
Muscle biopsy: Usually necessary to firmly establish the diagnosis of CIM

Provider documentation should clearly differentiate between critical illness myopathy and critical illness polyneuropathy to capture accurate code assignment.

Example Scenario:
A patient admitted to the ICU for sepsis with ARDS secondary to COVID-19 pneumonia has a prolonged recovery due to difficulty weaning off the ventilator. The provider documents critical illness neuropathy.

Assign the principal diagnosis code for sepsis with secondary diagnosis codes for ARDS, COVID-19 pneumonia, and critical illness polyneuropathy (G62.81).
A query could be considered for critical illness myopathy (G72.81) to add an additional CC if sufficient clinical indicators are present.

Each code impacts risk adjustment methodologies differently.

Additional Tips

Critical illness myopathy is underrecognized because it has a clinical appearance that is similar to critical illness polyneuropathy.
There are no identified treatment protocols other than preventative and supportive measures, with a primary focus on rehabilitation and mobilization of the patient.
CIM/CIP affects over a third of severely critically ill patients and more than a quarter of those requiring ventilatory assist for at least seven days.
Almost 100% of patients who demonstrate multiple organ failure experience CIM/CIP.
Record reviews should consider the presence of immobility-related complications such as DVT, pressure injuries, and aspiration pneumonia.
CIM and CIP can also be seen in other hospital settings and can manifest in patients with a severe illness that complicates care.

 References:

American Hospital Association. (2024). Coding Handbook, Disease of the Nervous System and Sense Organs; Critical Illness Myopathy.
Gutmann, L., & Gutmann, L. (1999, May). Critical Illness Neuropathy and Myopathy. JAMA Neurology. Retrieved from: Critical Illness Neuropathy and Myopathy | Critical Care Medicine | JAMA Neurology | JAMA Network
Prescott, L. & Manz, J. (2023). 2024 ACDIS Pocket Guide. The Essential CDI Resource (pp. 123-127). HCPro.
Shepherd, S., Batra, A., & Lerner, D. (2023, August). Review of Critical Illness Myopathy and Neuropathy. NIH. National Library of Medicine. National Center for Biotechnology Information. Retrieved from: Review of Critical Illness Myopathy and Neuropathy - PMC (nih.gov)

Introduction to NTAP: New Opportunities for Hospitals

brandon.uasi@gmail.com (Brandon Losacker) — Tue, 26 Nov 2024 00:51:42 GMT

In 2021, the New Technology Add-on Payment (NTAP) program was created by The Center for Medicare & Medicaid Services (CMS) to increase the use of new inpatient technologies in the Medicare population. CMS uses NTAP codes for qualifying products that promise improvement in process or outcomes. Additionally, these new medical services and technologies are eligible for an add-on payment known as NTAP which presents significant reimbursement opportunity for hospitals and healthcare systems that adopt these technologies.

Eligibility Criteria for NTAP Payments

To be eligible for the NTAP, these technologies must meet the following 3 criteria. When the following criteria are met, the NTAP payments are significantly greater than the standard Medicare Severity Diagnosis-Related Group (MS-DRG).

1.) Technology must be new within 2-3 years of market introduction.

2.) The technology must “substantially improve the diagnosis or treatment relative to currently available technologies and are inadequately paid otherwise under the current diagnosis-related group (DRG) reimbursement rates.”1

3.) The technology is deemed inadequately compensated under the current MS-DRG, as its average standardized charge for inpatient cases exceeds the set cost threshold.

FY 2025 Program Expansion: 39 New Technologies Approved

The number of approved technologies has increased each year since its inception. The FY 2025-year list is the most extensive since the program began and includes 39 Total NTAPs.

• CMS finalized the continuation of new technology add-on payments for 24 existing new technologies

• CMS finalized discontinuing new technology add-on payments for 7 current new technologies

• CMS finalized 16 of the original 27 new technologies submitted for new technology add-on payments under the traditional and alternative pathways

Financial Impact: What NTAP Can Mean for Your Hospital’s Reimbursement

According to CMS, new technology add-on payments are limited to the lesser of 65% of the costs of the technology, or 65% of the amount by which the costs of the case exceed the standard MS–DRG payment”.

The most substantial financial impact approved for FY 2025 Casegevy and Lyfgenia. Both are medications for gene therapies that treat sickle cell disease. These medications qualify for 75% NTAP amount resulting in a maximum payment of $1.65 Million for Casgevy and $2.32 Million for Lyfgenia.

Key Steps to Maximize NTAP Reimbursement

For hospitals and health systems, it is essential to take the following steps to ensure full NTAP reimbursement:

Accurate Coding: Make sure the correct ICD-10-PCS code(s) are included on claims to qualify for NTAP payments. Missing or inaccurate codes can lead to lost revenue.

Annual Review of NTAP Services: Each year, inpatient coding staff should review the latest list of approved NTAP services and technologies to stay updated on new opportunities for reimbursement.

Routine Audits: Conduct regular internal and external audits to confirm that all eligible procedures and technologies are correctly coded and reimbursed. These audits help identify and prevent potential revenue leakage.

Taking these proactive measures can help ensure your hospital captures all eligible NTAP reimbursements.

Not Sure if You’re Capturing All Possible NTAP Revenue?

Contact UASI for a comprehensive NTAP assessment. Our expert audit team is ready to help your hospital secure eligible NTAP payments and maximize revenue potential.

Do not let money slip through the cracks - Reach Out Today!

References

1. Adoption and Trends in the Medicare New Technology Add-On Payment Program - PubMed Central (PMC)

2. New Medical Services and New Technologies - Centers for Medicare & Medicaid Services (CMS)

Optimizing The Revenue Cycle: Insights from Leslie Vairo, Senior Consulting Director at Vizient

brandon.uasi@gmail.com (Brandon Losacker) — Tue, 26 Nov 2024 00:40:30 GMT

In today’s complex healthcare environment, optimizing the revenue cycle is more crucial than ever. As healthcare systems face increasing financial pressures, effective revenue cycle management (RCM) is essential for maintaining both operational efficiency and financial health. Leslie Vairo, Senior Consulting Director in Revenue Cycle at Vizient, is at the forefront of helping health systems navigate these challenges. With her broad experience in healthcare and finance, Leslie's expertise is key to helping enhance hospital operations and maximize revenue streams.

As a leading healthcare performance improvement organization, Vizient partners with more than half of US healthcare organizations. The organization provides end-to-end assessments that help organizations improve performance, increase revenue, and optimize their operations.

By working closely with health system leadership, Vizient conducts assessments of the revenue cycle process, that include denials management to coding accuracy, identifying areas where there is revenue leakage. The goal is to develop long-term strategies for sustainable improvement.

3 Common Revenue Cycle Challenges

During assessments, Leslie noted that Vizient often encounters recurring issues that contribute to lost revenue

Denials Management: Often, hospitals struggle with authorization errors, inaccurate coding, and unresolved payment issues, all of which can delay or prevent reimbursement. These issues are exacerbated by outdated systems and a lack of standardized processes across different payers, especially with Medicare and other insurers that have different billing guidelines.
Aging Coding Staff & Coding Accuracy: The healthcare industry faces a growing shortage of qualified medical coders, which has led to an aging coding workforce. In addition, Leslie noted that coding accuracy is a major issue, with some facilities reporting accuracy rates below 90%. Hospitals often don’t realize how much this shortfall costs them in lost revenue. The financial strain is also compounded by the backlogs of charts that is a direct result of the medical coding staff shortage.
Revenue Leakage: Underpayments or overpayments are another key issue that delays revenue flow. Often referred to as revenue leakage, these discrepancies result from inefficient claims processing or errors in billing, leading to delayed or lost payments. Leslie’s assessments reveal that many hospitals have significant opportunities to recoup revenue by improving accuracy in their coding and billing procedures.

People, Process & Partnerships

Hospitals are often eager to invest in new technologies, but Leslie points out that technology alone is not enough. Many hospitals purchase systems like EPIC or are now considering AI, hoping the technology will automatically improve their revenue cycle performance. However, without addressing the people and processes that drive the technology, the return on investment (ROI) is often limited. Hospitals must focus on aligning technology with the necessary skill development and change management to maximize its effectiveness.

One of the barriers Leslie encounters is the resistance to change from hospital staff, particularly when it comes to legacy teams that have not looked at or updated their program’s operations. These barriers can be especially pronounced when hospitals are presented with data analysis that shows they are leaving millions of dollars on the table due to inefficiencies in their revenue cycle. Overcoming this resistance requires not only clear communication in these assessments but also demonstrating the tangible financial benefits that can result from program optimization.

As hospitals strive to address these challenges, especially in the face of staffing shortages, it becomes necessary to partner with external vendors to fill critical roles in the revenue cycle. Leslie says that partners like UASI can bring much-needed specialized resources to help streamline the revenue cycle and stay up to date in a dynamic environment. These partnerships also enable hospitals to access skilled professionals who can address coding and billing challenges while maintaining compliance.

Advice for New Rev Cycle Leaders

For new leaders stepping into revenue cycle roles, Leslie offers several key pieces of advice to help set them up for success:

1. Review Historical Data : Look back at accounts receivable (AR) and collections trends to establish a benchmark. Most hospitals focus on current performance without comparing it to historical data, which makes it harder to identify trends and areas for improvement.

2. Build Strong Relationships : Work closely with hospital executives and make sure that everyone understands the importance of the revenue cycle. As Leslie points out, the revenue cycle is an integral part of a hospital’s financial health and getting buy-in from leadership is essential for driving change.

The Path Forward for Health Systems

Revenue cycle management is more than just a financial function, it is a critical component of operational success and therefore, impacts patient care. By addressing issues like coding accuracy, denials management, and staffing shortages, hospitals can unlock significant revenue opportunities and improve their overall financial health. Hospitals that take a comprehensive approach to their revenue cycle will be better positioned to deliver high-quality care while maintaining financial sustainability.

Reach out today to learn how a UASI & Vizient partnership can help impact quality outcomes and improve organizational sustainability.

Contact Us Today!

Transient Tachypnea of the Newborn ICD-10-CM Coding

Wed, 13 Nov 2024 16:36:07 GMT

Transient Tachypnea of the Newborn (TTN): ICD-10-CM Coding and Clinical Guidance

Overview of Transient Tachypnea of the Newborn (TTN)

TTN : a parenchymal lung disorder characterized by pulmonary edema resulting from delayed resorption and clearance of fetal alveolar fluid. It is the most common cause of respiratory distress in late preterm and term infants and is generally a benign, self-limited condition.

Clinical Manifestations of TTN

Onset usually between the time of birth and two hours after delivery
Tachypnea – most common feature with respiratory rate > 60 breaths per minute
Infants with more severe disease may exhibit:
Cyanosis
Increased work of breathing which includes:
Nasal flaring
Mild intercostal and subcostal retractions
Expiratory grunting
Anterior-posterior diameter of the chest may be increased
Typically with clear lungs (no rales/rhonchi)
Mild to moderate TTN are symptomatic for 12-24 hours but signs may persist as long as 72 hours in more severe cases
Characteristic radiographic features:
CXR – increased lung volumes with flat diaphragms, mild cardiomegaly, prominent vascular markings in a sunburst pattern originating at the hilum, fluid in the interlobar fissures, pleural effusions, alveolar edema appearing as fluffy densities. There are no areas of alveolar densities or consolidation
Lung US – pulmonary edema, compact B lines, double lung point, regular pleural line without consolidation

Differential Diagnosis for Neonatal Respiratory Distress

TTN is a benign disorder and pathologic conditions that also present with respiratory distress must be excluded.

Pneumonia – chest radiography differentiates PNA from TTN as neonatal PNA is characterized by alveolar densities with air bronchograms or patchy infiltrates, not seen in TTN.
Sepsis – infants with sepsis and respiratory distress are differentiated from those with TTN with the persistence of additional symptoms and the lack of the characteristic chest radiographic findings of TTN.
Congenital cardiac disease - TTN is distinguished from congenital heart disease by physical findings (e.g., heart murmur, abnormal precordial activity), chest radiography, pre- and post-ductal pulse oximetry, and echocardiography.
Respiratory distress syndrome – differentiated from TTN with a characteristic chest radiograph of a ground glass appearance with air bronchograms. Caused by surfactant deficiency most common in very preterm infants.

ICD-10-CM Coding for Transient Tachypnea of the Newborn

Code for Transient tachypnea of newborn (TTN) falls under ICD-10 Chapter 16 – Certain conditions originating in the perinatal period [P00-P96]

P19-P29 – Respiratory and cardiovascular disorders specific to the perinatal period
P22 - Respiratory distress of newborn
P22.0 – Respiratory distress syndrome of newborn
P22.1 – Transient tachypnea of newborn
P22.8 – Other respiratory distress of newborn
P22.9 – Respiratory distress of newborn, unspecified

Additional Tips:

TTN is also documented as Respiratory distress syndrome Type II, Wet lung syndrome
Tachypnea alone is just a symptom
Most common risk factors for TTN include prematurity, Cesarean delivery, maternal diabetes, maternal obesity, maternal asthma
Infants with TTN rarely require a fraction of inspired oxygen (FiO2) >0.4.

Works Cited

Johnson, K. E. (2021, August 30). Transient tachypnea of the newborn. UpToDate. www.uptodate.com/contents/transient-tachypnea-of-the-newborn

“Respiratory Conditions Neonatal.” Pro ACDIS Pocket Resource Online, pro.acdis.org/inpatient/conditions/respiratory-conditions-neonatal. Accessed 4 Dec. 2023.

Cracking the Code on Medicare Advantage Profitability

brandon.uasi@gmail.com (Brandon Losacker) — Fri, 08 Nov 2024 15:02:28 GMT

Can Providers Truly Win?

With Medicare Advantage growing rapidly, providers are asking, "Is it really possible to balance high-quality care with profitability?" In short, YES—but it requires a shift in thinking and some serious investments in data and tech.

Medicare Advantage (MA) plans have gained popularity as a way for healthcare providers to deliver high-quality, proactive medicine while also maintaining profitability. With more seniors enrolling in Medicare Advantage, it has become an attractive option for providers to streamline operations, improve quality outcomes, and increase revenue. In a perfect Medicare Advantage world, patients are kept healthy by seeing providers routinely to prevent sickness while providers can still be profitable without “relying” on patients getting sick before being seen. But can we thread that needle in a historically fee-for-service (FFS) healthcare society?

Medicare Advantage vs. Traditional Medicare

Medicare Advantage, also known as Medicare Part C, is an alternative to traditional Medicare. It is offered by private insurers and covers the same services as original Medicare (Parts A and B) but often includes extra benefits like dental, vision, and prescription drug coverage. Healthcare providers contract with these insurance companies to deliver care to patients enrolled in MA plans.

Medicare Advantage works on a fixed-payment model (sometimes interchangeably called capitated payments). This means that insurers receive a set amount per patient from Medicare, regardless of how much care the patient requires. Providers share in this payment, creating an incentive to manage costs efficiently while delivering high-quality care.

How Value-Based Care Fits In

Value-Based Care (VBC) is a model that focuses on improving patient outcomes while reducing healthcare costs—a perfect strategy! But does it work…for all parties?

Under this model, providers are rewarded for keeping patients healthy and reducing the need for expensive interventions. This differs from the traditional FFS model, where providers are paid based on the quantity of services rather than quality. In Medicare Advantage plans, Value-Based Care is critical. Providers can increase profitability by delivering care that prevents hospitalizations and other high-cost services. For example, investing in preventive care, patient education, and chronic disease management helps keep patients healthier and reduces the overall cost of care. Providers excelling in these areas can share in the savings through incentive payments offered by insurers. This incentive taps into our healthcare system's potential, but it's often easier said than done.

Leveraging Risk Adjustment to Increase Revenue

In addition to preventive care, accurate patient documentation plays a pivotal role in MA profitability. This is where Risk Adjustment comes into play.

Risk adjustment is the process by which Medicare adjusts payments to insurers and providers based on the health status of their patient population. Sicker patients generally require more care, so insurers are paid more for managing these higher-risk patients. In turn, providers who accurately report their patients’ health conditions are reimbursed accordingly.

For healthcare providers, optimizing risk adjustment is crucial. By ensuring that all patient diagnoses are correctly documented and coded, providers can secure higher reimbursement rates. This involves thorough patient assessments, accurate coding, and up-to-date medical records. Regular reviews of coding practices and investing in staff training can help avoid underreporting or misreporting conditions that could lead to lower payments. One could argue that educating your staff on what MA/VBC/RA means and how it works differently than FFS is the single greatest strategy for ensuring the success of an MA population and profitability.

The Path to Profitability

Healthcare providers can become profitable with Medicare Advantage plans by focusing on three key areas:

Efficient Care Management: Implementing care coordination and population health strategies helps providers manage chronic conditions and prevent costly interventions, resulting in better patient outcomes and reduced healthcare costs.
Quality Performance Incentives: Providers who meet quality benchmarks set by Medicare Advantage plans can earn additional bonuses. This makes investing in patient satisfaction, preventive care, and health outcomes a profitable strategy.
Optimizing Risk Adjustment: By accurately documenting patient conditions, providers ensure they receive appropriate payments that reflect the true cost of care. This requires strong clinical documentation and coding accuracy.

So - Is it Possible to Be Profitable in a Medicare Advantage World?

YES. Risk-based payments are not going away. They are becoming a higher percentage of patient populations across the country. Proactively implementing new strategies early, instead of being caught off-guard later, is key to setting providers up for success. Medicare Advantage plans offer a unique win-win-win scenario for providers to be profitable WHILE patients remain healthy WHILE the burden of increasing healthcare costs is reduced.

UASI Welcomes Rachel Mack as Managing Consultant in Clinical Documentation Integrity

brandon.uasi@gmail.com (Brandon Losacker) — Fri, 18 Oct 2024 14:27:44 GMT

Cincinnati, OH — UASI is excited to announce the addition of Rachel Mack, MSN, RN, CCDS, CDIP, CCS, CRC, to the team as Managing Consultant in Clinical Documentation Integrity (CDI). Rachel brings over 15 years of experience in CDI and healthcare management, with a well-rounded background as a CDI Specialist, Educator, and Auditor. Her expertise in inpatient hospital CDI/coding, CDI technology, risk adjustment methodologies, and Medicare will significantly enhance UASI's commitment to delivering exceptional documentation solutions.

Rachel has demonstrated her dedication to advancing CDI through her strong leadership in program and project management, with a Master's degree in Nursing Administration from Jacksonville University. She has worked closely with physicians to implement effective CDI strategies and has a proven track record in PSI prevention and Medicare compliance.

“I am passionate about all things CDI and am thrilled to bring my experience to UASI,” said Rachel Mack. “I look forward to working with a team that shares my commitment to enhancing healthcare outcomes through innovative CDI practices.”

Rachel's industry influence extends beyond her work with hospitals. She has been a sought-after speaker at major industry conferences, including her recent presentation on Social Determinants of Health (SDoH) at the 2023 ACDIS Conference alongside Connie Ryan. She also organized and presented at Vizient’s webinar series in 2021, 2022, and 2023, covering topics like CDI and Cardiac Surgery, Sepsis, Respiratory Failure, Risk Adjustment, and PSIs/HACs. Rachel's expertise and thought leadership were also featured at several ACDIS Conferences.

About UASI

For over four decades, UASI Solutions has led the healthcare industry in revenue cycle management, providing tailored solutions to optimize fiscal performance and drive sustainable growth. Established in 1984, our commitment to innovation and client success has solidified our position as trusted partners nationwide. With a comprehensive suite of services, including Remote Coding, Clinical Documentation Improvement, and Revenue Integrity, we remain dedicated to delivering value and driving results for our clients every step of the way.

For more information, please visit www.uasisolutions.com .

SDoH Can Make a Big Difference in Patient Care and Reimbursement

Fri, 18 Oct 2024 13:50:43 GMT

Healthcare is evolving, and as we move forward with quality care and compassion, it’s crucial to address the factors that significantly impact patient outcomes beyond traditional medical care. Social determinants of health (SDoH) are these non-medical factors—such as access to food, stable housing, transportation, and utility services—that influence a person's overall health and treatment outcomes. By effectively addressing and coding these determinants, providers can enhance care while also accessing additional reimbursement opportunities.

CMS Strategic Plan

“The Centers for Medicare & Medicaid Services (CMS) infuses health equity in everything it does. CMS is working to advance health equity so that each person has a fair and just opportunity to attain their highest level of health regardless of their age, race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.” CMS wants to make sure that all individuals and families have access to quality healthcare. To do this CMS has to remove the barriers to healthcare and support and partner with providers to ensure that every person and family can access care they need.

Starting in January 2024, CMS began offering coverage for HCPCS code G0136. This coverage allows providers to be reimbursed when they use a standardized, evidence-based SDoH risk assessment tool that evaluates crucial areas such as food insecurity, housing instability, transportation needs, and utility difficulties.

To comply with G0136, providers must use validated tools that have been independently tested. The 2024 MPFS final rule specifies some approved tools, including:

CMS Accountable Health Communities Tool

Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE)

Medicare Advantage Special Needs Population Health Risk Assessment

The key is to find a tool suitable for your practice’s patient population while ensuring it meets CMS requirements. Documentation of the tool used in the patient record is also critical.

Hospital Outpatient Quality Reporting Program (OQR)

CMS is expanding its focus on SDoH beyond inpatient settings. The Hospital Outpatient Quality Reporting Program (OQR), a pay-for-reporting quality program, requires hospital outpatient departments to meet specific quality reporting requirements. Failure to do so results in a 2% reduction in their annual payment update. CMS is proposing to adopt the screening of Social Drivers of Health measure, with voluntary reporting starting in CY 2025, followed by mandatory reporting beginning in CY 2026.

This expansion reflects CMS’s recognition of the importance of social factors in shaping health outcomes. It provides healthcare providers with the tools to identify at-risk populations and develop targeted interventions. The Commitment to Health Equity measure further encourages healthcare organizations to integrate equity into their strategic and operational goals, fostering a culture of accountability and continuous improvement.

Expanded Reimbursement Opportunities

CMS is committed to advancing health equity and has included measures to support providers and hospitals in addressing social drivers of health. For example, the new policy finalized for FY 2024 recognizes the higher costs that hospitals face when treating patients experiencing homelessness or housing insecurity. This policy introduces new codes effective from October 1, 2024, which will be classified as complications or comorbidities (CCs), thus increasing reimbursement for specific diagnosis-related groups (DRGs). These codes include:

Z59.10 (Inadequate housing, unspecified)

Z59.11 (Inadequate housing, environmental temperature)

Z59.12 (Inadequate housing, utilities)

Z59.19 (Other inadequate housing)

Z59.811 (Housing instability, housed with risk of homelessness)

Z59.812 (Housing instability, housed, homelessness in past 12 months)

Z59.819 (Housing instability, housed, unspecified)

Real-World Scenarios: How SDoH Coding Can Make a Difference

Here are some examples where documenting SDoH impacts patient care and enhances reimbursement:

A patient is diagnosed with hypothermia, and the physician documents that their home does not have heating. Code: Z59.11 (Lack of heating).
A child’s record shows a history of food insecurity due to financial difficulties at home, leading to hunger. Code: Z59.48 (Lack of food).
A patient misses multiple appointments due to transportation issues. Code: Z59.82 (Lack of transportation).
A patient becomes homeless following the foreclosure of their home. Code: Z59.819 (Housing instability).

Why This Matters for Your Practice

Incorporating SDoH documentation not only improves patient care but also opens up significant reimbursement opportunities. UASI is here to guide you through these changes and help your practice implement these assessments seamlessly. Our expertise ensures your compliance with the latest CMS guidelines, helping you maximize reimbursement potential while enhancing patient outcomes.

Take Action Today

Don’t let your practice fall behind in leveraging these opportunities. Contact UASI to learn how our clinical documentation and coding solutions can empower your practice to succeed. Together, we’ll build a more equitable, efficient, and effective healthcare environment for your patients.

Acid / Base disorders - CDI Scenario Discussion

Wed, 16 Oct 2024 13:05:24 GMT

Acid-Base Disorders in CDI: Lactic Acidosis Query and ICD-10-CM Coding Guidance

Clinical Scenario: Acid-Base Imbalance in Crohn’s Disease

H&P: 51-year-old female with Crohn’s disease, morbid obesity, and a BMI of 42 presents from home in a private vehicle with 4 days of fever, severe abdominal pain, diarrhea, and nausea and vomiting.

Patient History, Vitals, and Clinical Findings

PMH: Hypertension, Crohn’s disease, and CKD Stage 3a with a baseline creatinine of 1.2

Home Medications: Stelera 90 mg SQ every 8 weeks (last dose 6 weeks ago), Prednisone 20 mg PO daily, Metoprolol 50 mg PO BID, and Lisinopril 20 mg PO daily

Vitals: B/P 99/56, HR 89, Temp 100.8, RR 18, Pulse ox 96% on room air

PE: Abdomen TTP, scant dark urine

Labs: Lactic Acid 4.2, WBC 18.5, Creatinine 1.5, CRP 105. Repeat lactic acid after fluid bolus 3.0 and 1.5.

CT: Abdomen revealing small-bowel wall thickening, mesenteric inflammatory stranding, and mesenteric adenopathy, partial small bowel obstruction. Impression: Crohn’s disease with partial obstruction

Treatment Course and Discharge Summary

Consult: GI consulted, NGT placed, started IV prednisone to be tapered to PO once pain subsides and having bowel movements again.

Discharge Summary: Crohn’s flare with partial small bowel obstruction. Treated with NGT tube, IV prednisone, pain medication, 2 L normal saline bolus & normal saline continuous IV @ 75 ml/hr. Patient is tolerating PO intake and having normal bowel movements. Outpatient GI follow-up in 1 week.

Discharge Medication: Prednisone increased to 40 mg PO daily, resume home medications of Metoprolol 50 mg PO BID, and Lisinopril 20 mg PO daily, and normal Stelera injection in 10 days.

CDI Query Opportunity: Lactic Acidosis

Question: Are there query opportunities based on the scenario stated above?

Discussion: The patient has exhibited the following risk factors and clinical indicators: 4 days of abdominal pain, diarrhea, and nausea & vomiting. Lactic Acid 4.2 with repeat lactic acid after fluid bolus 3.0 and 1.5. Crohn’s disease with partial small bowel obstruction and CKD stage 3a.

Diagnostic Criteria for Lactic Acidosis

Lactic acid > 4

Lactic Acid > 2 plus pH < 7.35

Lactic Acid > 2 plus Anion gap > 12

Treatment Indicators Supporting Lactic Acidosis

Normal saline IV fluid bolus 2,000 ml

Normal saline IV continuous rate 75 ml/hr

UASI Recommends: Query for Lactic Acidosis

Impact of Documentation on Coding and DRG

Documentation without clarification:

Principal Diagnosis: K50.012 Crohn’s disease of small intestine with intestinal obstruction

Secondary Diagnosis: E66.01 Morbid obesity, Z68.41 BMI 40.0-44.9 adult

Working DRG: 386 Inflammatory bowel disease with CC

RW: 0.9898

GLMOS: 3.4

SOI/ROM: 1/1

Documentation with clarification:

Principal Diagnosis: K50.012 Crohn’s disease of small intestine with intestinal obstruction

Secondary Diagnosis: E66.01 Morbid obesity, Z68.41 BMI 40.0-44.9 adult, E87.20 Acidosis, unspecified

Working DRG: 386 Inflammatory bowel disease with CC

RW: 0.9898

GLMOS: 3.4

SOI/ROM: 2/2

CDI Educational Tips for Acid-Base Disorders

Acidosis is classified to code E87.20. Inclusion terms are lactic acidosis and metabolic acidosis.

E87.20 provides a CC as a secondary diagnosis.

The treatment of metabolic acidosis and alkalosis depends entirely on its cause. The underlying cause should also be treated.

Conditions often associated with acid/base imbalance include diarrhea, poisoning (metabolic acidosis), vomiting, dehydration (metabolic alkalosis), sepsis (elevated lactate), and COPD (respiratory acidosis).

Interpreting Lactate Levels and Clinical Significance

An elevated lactate/lactic acid does not necessarily indicate lactic acidosis which requires elevated lactate in addition to acidosis (pH<7.35). Lactate levels < 2.0 are normal, and transient slight elevations are often not clinically significant. For example, a slightly elevated lactate of 2.2 on admission for which the lactate level is simply repeated.

Laboratory Indicators of Acidosis or Alkalosis

Important Disclaimer

This is a short synopsis of a possible patient record and is not intended to be all-inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.

Works Cited

Association of Clinical Documentation Integrity Specialists (ACDIS). (2023). Acid-base disorders. Available at: https://pro.acdis.org/inpatient/conditions/acid-base-disorders

Pinson, R., & Tang, C. (2023). CDI Pocket Guide. Available at: https://cdiplus.com

Fee-for-Service (FFS) vs. Value-Based Care (VBC)

Thu, 26 Sep 2024 15:10:42 GMT

Fee-for-Service (FFS) vs. Value-Based Care (VBC):
Understanding the Shift in Healthcare Compensation Models

Navigating the transition from fee-for-service to value-based care requires balancing quality outcomes with sustainable provider compensation.

In the ever-evolving landscape of healthcare, two major compensation models are generating substantial attention—Fee-for-Service (FFS) and Value-Based Care (VBC). These reimbursement methods are transforming how providers are paid for their services, impacting the entire healthcare ecosystem. Understanding how these models function and their implications on both patient outcomes and provider compensation is essential as healthcare continues to shift toward more outcome-focused systems.

The Traditional Model: Fee-for-Service (FFS)

For decades, Fee-for-Service (FFS) has been the standard approach for compensating healthcare providers. In this model, providers are paid based on the volume of services they perform —whether it's a test, procedure, or consultation. This incentivizes providers to see more patients and perform more services, as payment is directly tied to the number of treatments delivered. While this model rewards high activity levels, it comes with an inherent risk: there’s potential for unnecessary treatments and tests to be performed, ultimately driving up healthcare costs without always improving patient outcomes.

Imagine FFS like paying a mechanic for every part they replace in your car, regardless of whether those parts truly needed to be changed. It may solve short-term issues, but over time, it can lead to over-servicing, higher costs, and no real improvement in the car's overall performance.

The Emerging Model: Value-Based Care (VBC)

In contrast, Value-Based Care (VBC) represents a significant shift in the way providers are compensated. Instead of paying based on the quantity of services provided, VBC rewards healthcare providers for the quality of care they deliver and their ability to improve patient outcomes. By focusing on preventive care and the management of chronic conditions, VBC aims to reduce the need for costly and unnecessary procedures, hospitalizations, and tests.

Under this model, physicians are incentivized to keep patients healthier in the long run. The emphasis is on delivering the right care at the right time, rather than maximizing the number of services rendered. Preventive care, early diagnosis, and effective management of chronic conditions are all core tenets of the VBC approach.

Picture VBC as having a mechanic who ensures your car runs smoothly for years by focusing on preventive maintenance, rather than waiting for problems to arise. It's not just about fixing immediate issues but ensuring long-term health and sustainability.

The Role of Physicians in Value-Based Care

Transitioning to VBC places a considerable responsibility on physicians, particularly within practice settings where much of the cost-saving and patient engagement work takes place. Physicians must now be more cognizant of the cost of care, actively engaging in preventive health strategies, and utilizing data analytics to track patient outcomes effectively.

With this shift comes a need for extensive data capabilities and population health management programs. Providers must leverage electronic health records (EHRs) not only for documentation but also for tracking performance metrics and reporting outcomes. This data-driven approach is essential to ensuring VBC programs succeed in improving health outcomes while simultaneously reducing overall healthcare costs.

The Future of Value-Based Care

While FFS still plays a role in today's healthcare environment, the momentum is undeniably shifting toward value-based models . In 2022, over half of healthcare payments were made through a VBC model, underscoring the growing adoption of this approach. However, the transition is far from complete, and significant work remains to ensure a smooth shift across the entire healthcare sector.

VBC holds the promise of addressing some of the most pressing issues facing the healthcare system today, including rising costs and inconsistent patient outcomes. As VBC programs continue to evolve, providers will be held increasingly accountable for improving patient outcomes, but they will also gain greater flexibility in how they deliver care, ensuring it is timely, appropriate, and cost-effective.

Call to Action

At UASI, we understand the complexities and challenges that come with transitioning to value-based care models. Our expertise in clinical documentation integrity (CDI) and healthcare reimbursement strategies can help healthcare providers navigate these changes efficiently. Let us assist you in optimizing your documentation, improving patient outcomes, and aligning with the future of healthcare compensation.

What’s Your ROI on Coding?

Wed, 18 Sep 2024 17:51:32 GMT

When you think about coding in your organization, do you consider it a cost center? Often, the direct costs such as salaries, benefits, and equipment dominate the conversation. But what if we shifted the focus to understanding coding as an essential investment in your healthcare operations rather than just another expense?

Beyond the Obvious Costs: The Hidden Impact of Coding

We often focus on direct costs, but it’s easy to underestimate the indirect ones that quietly accumulate. Supervisory time, for example, is often overlooked as an indirect cost. Recruiting, testing, and turnover contribute further, along with quality assurance, ongoing education, and training. With every regulatory change and code-specific nuance, the demands increase—requiring more time, resources, and money. These factors don’t just affect your bottom line; they can significantly impact your Return on Investment (ROI) in ways that are frequently underestimated.

The Real ROI of Accurate Coding

The accuracy of your coding has a direct influence on your organization's financial health. Consider this: what would a mere 1% increase in coding accuracy mean for your top line? Not only could it boost revenue, but it could also reduce re-work costs and significantly cut down on denials. A lower denial rate means faster cash flow, less time spent on rework, and fewer headaches.

Many systems often handle coding internally, focusing only on the direct costs. However, this approach overlooks not only the significant indirect costs—like supervisory time and training—but, more importantly, the impact on accuracy and productivity. These hidden factors can make a big difference in overall performance, which is why outsourcing your coding can provide a more efficient and accurate solution.

*“If you are questioning to remain in-house or outsource, it is imperative that you consider all costs and rewards – coding was costing me about $400k per month in lost revenue due to improper coding and lost charges (on $116m gross revenue, now $230m, so it would be higher).”

Shifting Focus: From Administration to Patient Care

What if your team could focus on what really matters—patient care—without the administrative burden of coding? Imagine the impact on your organization if you could shift the focus from managing coding staff and processes to enhancing patient outcomes.

6 Key Reasons to Outsource Your Coding

Outsourcing your coding might be the game-changer your organization needs. Here’s why:

Coder Shortage: The ongoing shortage of experienced coders, exacerbated by factors like ICD-10 implementation and the COVID-19 pandemic, makes finding and retaining qualified staff increasingly difficult.
Quality and Productivity Demands: With evolving healthcare technology and constant regulatory changes, coding has become more complex. Meeting productivity and quality standards is challenging, especially for in-house teams.
Fluctuating Workloads: Your coding needs fluctuate, but your costs don’t have to. Outsourcing allows you to scale up or down based on demand, saving you from the expenses of overstaffing or temporary hires.
Geographical Challenges: Whether you're in a rural area or an underserved urban zone, outsourcing circumvents the difficulties of local recruitment by offering a broader talent pool.
Improved Data Outcomes: Accurate and efficient coding is crucial for improving key data metrics that impact your organization’s reputation and reimbursement. By outsourcing your coding, you can enhance outcomes related to Health Grades, Quality Scores, CMS Star Ratings, and Risk Adjustment Factor (RAF) scores.
Financial Relief: Outsourcing reduces the burden of managing an internal coding department. It cuts costs associated with recruitment, education, training, and retention, allowing you to focus resources where needed—patient care—and improves your overall ROI.

*“We know it takes at least 18 months to get a coder proficient and accurate. I know our cost of labor is extremely high and would cost us considerably more per FTE when opportunity costs are calculated (lost revenue due to coding errors, missed charges, education, CDI, etc.)”

Challenges and Opportunities: Beyond Just Numbers

It’s not only about costs. The workforce is changing, and managing people is becoming harder. Burnout among coding staff is real, and it’s a growing concern that impacts both productivity and quality. Additionally, the coding workforce is aging, with many experienced coders approaching retirement. This looming wave of retirements is likely to exacerbate existing staffing challenges, making it even more difficult to maintain a fully staffed and skilled team. Continuous learning and development aren’t just nice-to-haves—they’re critical to success. As the demands on your coding team increase, are your leaders equipped to manage these challenges?

UASI’s Solution: Experience and Expertise at Your Service

This is where UASI comes in. With over 40 years of experience, we’ve honed our processes to deliver better results at the same or even lower cost than maintaining an in-house team.

Here’s how we can transform your operations:
• Reduced Headaches: We take on the challenges of recruiting, training, and managing coding staff, so you don’t have to.
• Flexibility and Expertise on Demand: We provide the expertise you need when you need it, allowing you to scale up or down based on your coding demands.
• Shared Success: We work as partners, with a focus on shared success and accountability.
• Focus on What Matters: Our services free up your team to focus on patient care, reducing in-house tension and administrative strain.

Highlighting the Benefits of Outsourcing Coding

*“With a coding outsource, organizations do not need to spend money, time, and resources in hiring, training, and retaining experienced coders. Outsourcing is a cost-effective solution to reducing an organization’s administrative costs, as well as decreasing the administrative strain in the HIM department. In consideration of a coding outsource, it’s important to develop a cost-benefit analysis as well as determining appropriate, reportable KPIs.”

“As I make changes to the RCM, one constant will be UASI because of their expertise and because of how they work with everyone on my side to effectively train my staff and to educate my providers.”

Proven Outcomes: A Client Success Story

Outsourcing of coding services has shown remarkable outcomes in terms of improved efficiencies and financial performance. Here are some notable results from a specific outsourcing client:
• Decrease in DNFB by 44% in 90 days
• Decrease in DNFC by 64% in 90 days
• Nearly 100% decrease in front-end claim edits, with coders resolving edits concurrently at the time of coding, leading to an increase in clean claims being released for billing sooner.
• Increased productivity, with all coders meeting or exceeding established productivity standards.
• Improved efficiency of the organization’s HIM staff, allowing them to focus on resolving EMR issues, obtaining needed provider documentation, addressing chargemaster issues, and other registration and billing challenges.

Outsourcing guarantees a qualified team to manage and perform the daily work associated with all coding needs, leading to measurable outcomes like improved DNFC and DNFB, enhanced coding quality, decreased coding edits, reduced denials, improved cash flow, and overall increased departmental efficiency.

Flexible Engagement Models: Designed for Your Success

At UASI, we offer two flexible ways to engage with our services:

• Monthly Subscription Fee to Shared Success Fee: We start with a straightforward monthly subscription, transitioning to a shared success fee model after six months. This approach allows for a seamless transition to outsourcing, where we can re-badge your existing staff where appropriate. After the initial period, we evaluate the success of the engagement, ensuring it aligns with your goals and expectations.

• Quick Results and Strategic Planning: Our model enables you to take quick action and see results rapidly. We begin with a thorough assessment to identify potential opportunities, propose a combination of a monthly fee and a shared success model, and allow your health system to evaluate the program for optimization. This data-driven approach ensures that you can determine the best path forward based on both strategy and measurable outcomes.

These flexible engagement models are crafted to provide immediate benefits while allowing you to refine your strategy over time. By partnering with UASI, you can be confident in a solution that meets your organization's specific needs, enabling you to focus on what matters most—delivering exceptional patient care while achieving financial success.

*CEO, West Coast Health System

Diabetes Mellitus with Hyperglycemia

Tue, 27 Aug 2024 16:08:34 GMT

Diabetes Mellitus: is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia.

The 2 main categories of diabetes mellitus are:

Type 1 - The body’s immune system destroys the beta cells within the pancreas, leading to an inability to produce insulin.
Type 1 diabetes requires daily insulin therapy.
Historically described as juvenile-onset diabetes.
Accounts for less than 10% of all cases of diabetes mellitus.
Type 2 - The body still produces insulin, but the body’s cells are unable to utilize the insulin efficiently, leading to insulin resistance.
Liver and fat cells are inefficient at absorbing the insulin, resulting in higher glucose levels and increased insulin production.
The pancreas loses the ability to produce adequate levels of insulin.
May require insulin replacement.

Hyperglycemia : Blood sugar > 140 mg/dL
Provider documentation should clearly identify diabetes complications as “hypoglycemia” or “hyperglycemia” instead of “uncontrolled diabetes” to ensure accurate code assignment.

Example: A patient with a history of type 2 diabetes was found to have blood sugars ranging from 150-220 mg/dL. The provider documents “uncontrolled diabetes” in the H&P.
A query should be sent to clarify the diagnosis as “Diabetes mellitus type 2 with hyperglycemia” for accurate capture of the diagnosis.
Diabetes mellitus type 2 with hyperglycemia is an Elixhauser variable and an HCC.

Provider documentation should clearly differentiate POA status of DM with hyperglycemia when related complications are also documented, such as HHS or DKA.

Example: When a provider documents hyperglycemia as POA and a second provider later determines the patient has DKA or HHS.
CDI should send a query for clarification of the POA status of documented conditions.
CDI would also send a clinical validation query if HHS or DKA is lacking sufficient clinical evidence to support the diagnosis.

Provider documentation should clarify if “diabetes type 2 with hyperglycemia” is a complication of a medical treatment to capture appropriate code assignment.

Example: A patient with pre-existing type 2 diabetes mellitus presented with hyperglycemia, and the provider notes hyperglycemia is likely secondary to autoimmune DM, which occurred following immunotherapy initiation.
Assign codes for Diabetes type 2 with hyperglycemia, and an additional code for the adverse effect of antineoplastic and immunosuppressive drugs.
If there is any question of a cause-and-effect relationship, a query would be warranted for clarification.
In the OP arena, look for an A1c > 7 to consider a query for control status, unless the provider documents a specific goal in the visit note i.e. A1c goal is < 7.5, etc.
NCQA / HEDIS Comprehensive Diabetes Care measure looks for HbA1c control (<8.0%).

See below:

A1C Chart

Additional Tips from Official Guidelines for Coding and Reporting:

If hyperglycemia is due to a complication of an insulin pump under dosing, T85.694-would be assigned followed by T38.3X6-underdosing of insulin/oral hypoglycemic drugs-assign additional complication codes related to under dosing.

Assign codes E10.69, Type 1 diabetes mellitus with other specified complication, E10.65, Type 1 diabetes mellitus with hyperglycemia, and E87.0, Hyperosmolality and hypernatremia for a patient with uncontrolled type 1 DM, hyperglycemia, and acute hyperglycemic hyperosmolar syndrome (HHS).

When hyperglycemia, poorly controlled, inadequately controlled, or out of control is documented, assign the code for diabetes with hyperglycemia- for example E11.65, Diabetes type 2, with hyperglycemia.

ICD-10-CM presumes a causal relationship between diabetes and several acute and chronic conditions. Remember the “with” guideline does not apply to NEC index entries and a cause and effect relationship should not be presumed. When ICD-10-CM does not presume a cause and effect relationship it is appropriate to query the physician to document the cause and effect.

When diabetes complicates pregnancy and is the reason for admission remember to assign the appropriate code from category “O24 Diabetes mellitus in pregnancy, childbirth, and the puerperium” as the first listed diagnosis.

References:

Coding Clinic for ICD-10-CM/PCS , Third Quarter 2020: page 30.

Coding Clinic for ICD-10-CM/PCS, First Quarter 2022: page 28.

Coding Clinic for ICD-10-CM/PCS, Second Quarter 2023: page 10.

Brutsaert, E., (2023, October). Diabetes Mellitus (DM). Merck Manuals Professional Version.
Retrieved from: Diabetes Mellitus (DM) - Endocrine and Metabolic Disorders - Merck Manuals Professional Edition

Prescott, L. & Manz, J. (2023). 2024 ACDIS Pocket Guide. The Essential CDI Resource. HCPro, 351-357.

ICD-10 is expanding subcategory E10 to identify stages of Presymptomatic Diabetes Mellitus

Tue, 27 Aug 2024 15:39:23 GMT

Presymptomatic Type 1 Diabetes Staging: ICD-10-CM Updates Effective FY 2025

Overview of ICD-10-CM Updates for Presymptomatic Diabetes

ICD-10 is expanding subcategory E10 to identify stages of Presymptomatic Diabetes Mellitus

Come October 1, we will now be able to identify diabetes at earlier presymptomatic stages. ICD -10 is expanding subcategory E10 to identify stage1 and 2 presymptomatic diabetes.

Understanding the Three Stages of Type 1 Diabetes

Type 1 diabetes can now be most accurately understood as a disease that progresses in three distinct stages.

STAGE 1 is the start of type 1 diabetes. Individuals test positive for two or more diabetes-related autoantibodies. The immune system has already begun attacking the insulin-producing beta cells, although there are no symptoms and blood sugar remains normal.

STAGE 2 , like stage 1, includes individuals who have two or more diabetes-related autoantibodies, but now, blood sugar levels have become abnormal due to increasing loss of beta cells. There are still no symptoms.

STAGE 3 is when clinical diagnosis typically takes place. By this time, there is significant beta cell loss and individuals generally show common symptoms of type 1 diabetes, which include frequent urination, excessive thirst, weight loss, and fatigue.

Works Cited

Type 1 Diabetes TrialNet. (n.d.). Type 1 diabetes staging classification opens door for intervention. Available at: https://www.trialnet.org/events-news/blog/type-1-diabetes-staging-classification-opens-door-intervention

"Out of Sight, Out of Mind” - A Cautionary Note for Hospitals Reducing Their Value-Based Care (VBC) Patient Populations

Tue, 20 Aug 2024 18:55:11 GMT

“Out of Sight, Out of Mind” - A Cautionary Note for Hospitals Reducing Their Value-Based Care (VBC) Patient Populations

We’ve all witnessed the ongoing power struggle between health systems and payors regarding how to implement Value-Based Care (VBC) initiatives effectively in a way that benefits everyone, including patients. VBC has the potential to improve quality, reduce costs, and enhance the stability of the entire health system. However, to date, health systems and payors have struggled to agree on contracts that protect both sides from downside risk while providing sufficient financial upside to lure them away from traditional fee-for-service (FFS) medicine.

This frustration has grown so significant that some health systems are pausing new VBC contracts and even withdrawing from existing ones to mitigate further financial losses. This is happening despite a record number of patients enrolling in Medicare Advantage plans.

The consensus in the industry is that VBC has become too big and popular among patients to disappear entirely. However, as hospitals attempt to reduce their financial risk by cutting the number of VBC patients they accept, they must be careful not to create even more risk by falling prey to the age-old idioms: “out of sight, out of mind” and “absent from view, absent from thought.”

What does this mean?

We all know that the more revenue a department generates, the more attention it receives from decision-makers. This approach makes sense under fee-for-service structures where there's no significant risk associated with focusing less on smaller service lines. However, VBC contracts can carry tremendous downside risk if not given the appropriate attention and diligence. This could ultimately lead to a disproportionate amount of financial risk relative to the volume of patients it represents.

If healthcare leaders shift their focus towards the larger population of upside-only FFS patients while reducing their VBC patient population, they could inadvertently make a costly mistake to their bottom line without even realizing it.

Even the most efficient health systems typically have operating margins of just 3-5%. With even a small proportion of VBC patients, if not managed appropriately, it doesn’t take much for those patients to have a significant negative impact on the operating margins that health systems work so hard to achieve.

The bottom line: If your health system is decreasing its VBC contracts or has yet to take on a large volume of these patients, be cautious not to create additional risk to your bottom line by neglecting this crucial patient population. Now, more than ever, tools and strategies for effectively managing your VBC patients are essential. Out of sight cannot be out of mind if you don’t want your Value-Based Care patients chipping away at the margins created by Fee-For-Service patients.

TOP GUN: Charmaine C. Hall

uasi.marketingit@uasisolutions.com (UASI SOLUTIONS) — Tue, 06 Aug 2024 04:00:46 GMT

We were honored to have Charmaine be our inaugural Top Gun Spotlight. Charmaine is the Senior Director of HIM, Coding & Revenue Management Administration at Orlando Health. Here is our interview with her.

UASI: What is your mini-biography, your history, how did you get into the industry?

Charmaine: My experience began as a manager in private practices in the Central Florida community. Transitioned to Orlando Health in 2008, in a role of physician operations management in charge of the onboarding process for new medical offices; to certified coders in which I managed the Out-Patient coding team for the physician practices and oncology services. My current role as Senior Director of HIM and Coding has been quite rewarding.

How long have you worked at your organization & what’s your favorite part of your role?

I have been with Orlando Health for 15 years. I am enthusiastic about mentoring my leadership team to achieve excellence and growth.

What is your superpower?

My superpower is leading with integrity with the required role and responsibility.

What are you most proud of in the last year?

Proud of the successful outcome with hospital coding services for FY-23.

What are you most excited for in the coming year?

Personally, I am most excited for my daughter’s wedding on September 1, 2024. Professionally, successfully completing the RHIA certification.

TOP GUN: Melissa Koehler

uasi.marketingit@uasisolutions.com (UASI SOLUTIONS) — Tue, 06 Aug 2024 03:58:04 GMT

After spending a year working on nursing pre-requisite courses, I quickly figured out that face-to-face patient care was not for me but was still interested in healthcare. I stumbled upon an opportunity to learn medical coding “on the job” and almost 30 years later, it has worked out well. I have worked for a variety of health information vendors and healthcare organizations throughout my career with positions ranging from ED coder to my current role as Director of Hospital Coding Operations & Quality for Inova Health System.

How long have you worked at your organization & what is your favorite part

of your role?

I have worked for Inova Health System for two and a half years. My favorite part of my role is tackling opportunities for improvement with my team and realizing the successes of our efforts and the positive impacts to healthcare data and the patient experience. It is great to see my team light up with realization of “Wow, we accomplished this!”.

What is your superpower?

My superpower, which can also be my kryptonite, is being highly analytical.

What are you most proud of in this last year?

Earning a doctorate degree in healthcare administration!

What are you most excited for in the coming year (either personally or professionally)?

I am most excited to see how technology can support the healthcare industry by helping to solve some widespread inefficiencies and staffing shortages many organizations are facing.

Is Your Risk Adjustment Program Contributing to Burnout?

uasi.marketingit@uasisolutions.com (UASI SOLUTIONS) — Mon, 05 Aug 2024 23:16:59 GMT

Burnout in healthcare is a significant and growing issue, affecting everyone from frontline clinical staff to administrative personnel. Despite ongoing efforts to tackle this challenge, burnout remains alarmingly high among physicians. According to the 2024 Medscape Physician Burnout & Depression Report, 49% of physicians are experiencing burnout, a modest improvement from the previous year’s 53%. This underscores the lingering impact of COVID-19 and the heightened pressures within the healthcare system.

Healthcare practices are juggling Fee-For-Service (FFS) and Value-Based Care (VBC) models simultaneously. This means that there is either one generalized process that effectively serves both models or two distinct processes, rules, tools, and approaches. The FFS model pushes providers to see more patients and perform more procedures, which can be overwhelming and lead to unnecessary services. On the other hand, VBC emphasizes quality care and chronic disease management over the long term, requiring various management methods beyond traditional encounters. Balancing these models and meeting compliance demands can be daunting and contribute to burnout.

Top 5 Strategies You Can Implement Now to Reduce Burnout

1. Simplify Administrative Tasks: Reducing bureaucratic tasks like charting and paperwork by employing Clinical Documentation Integrity (CDI) and coding professionals allows providers to focus more on patient care and less on administrative duties. Organizations that utilize CDI professionals reduce denials, re-work, and improve the effectiveness of their queries. This reduces the administrative burden not only for physicians but also for CDI and coding professionals.

2. Proactive Scheduling of Patients: Prioritizing Annual Wellness Visits (AWVs) and transitional care visits using Risk Adjustment Factor (RAF) scores, or Hierarchical Condition Categories (HCCs) helps manage resources efficiently and reduces provider burnout. Using data to understand current RAF scores and recapture opportunities by patient ensures that the patients with the most impact are seen at least annually and given their chronic conditions, more frequently as appropriate.

3. Conduct Prospective CDI Reviews: Ensuring CDI professionals prospectively review records and communicate priority clinical indicators guarantees accurate medical documentation, reduces the time providers spend researching patient records in advance, and ensures optimal outcomes while reducing re-work.

4. Effective Use of Coders: Utilizing professional coders to handle diagnosis codes for claims reduces compliance issues, lost revenue due to over-coding or under-coding, and increased frustration. A streamlined coding process ensures that claims are processed expeditiously, resulting in faster cash flow. This not only saves time but also reduces compliance risks and the administrative burden on physicians.

5. Leverage Technology: Implementing advanced technology solutions, such as our proprietary software RAF Vue™️ , can significantly enhance efficiency and accuracy. Instant insights into chronic code capture and recapture opportunities allow for quick identification of patients with the greatest treatment and financial impacts. With a centralized, patient-level view and automatic calculation of reported and potential RAF scores, RAF Vue™️ generates comprehensive reporting at the patient, provider, and reviewer levels. Best of all, RAF Vue™️ can achieve immediate go-live without requiring EMR integration, reducing the technological burden on your practice.

Comprehensive Support from UASI

At UASI, we specialize in guiding healthcare organizations through the intricacies of risk adjustment and value-based care. We evaluate programs, assess needs, identify priorities, and create effective strategies to reduce administrative burdens, enhance care quality, and improve financial outcomes. Our goal is to support your practice in reducing burnout and improving patient care.

Let us help you navigate the complexities of risk adjustment and value-based care to achieve sustainable success.

UASI’s Risk Adjustment Maturity Model Explained

uasi.marketingit@uasisolutions.com (UASI SOLUTIONS) — Mon, 05 Aug 2024 22:21:57 GMT

Our HCC experts Nancy Koors, Vice President of Corporate Development and Mary Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, Vice President of Consulting Services recently teamed up with Colleen White, MSM, BSN, RN, CPC, Ambulatory CDI Program Manager at ChristianaCare, for a webinar discussing Successful HCC Risk-Adjusted Programs: Tactics to Manage Your Risk-Adjusted Population. ChristianaCare is featured on the World’s Best Hospitals 2022 list by Newsweek and among America’s 50 Best Hospitals 2022 according to Healthgrades.

The webinar primarily focused on UASI’s Risk Adjustment Maturity Model and its four phases: Explore, Define, Implement, and Optimize, as well as lessons learned from ChristianaCare as they progressed through each phase. Here is a breakdown of each phase. Keep reading to find out in what phase your organization is.

Explore: An organization is aware that they have a growing risk-adjusted patient population, but they may or may not know how many patient lives they are managing or their RAF scores. Whether they know their RAF Scores or not, they probably realize that their scores are not a true reflection of the health of their population. There are a lot of uncertainties in this phase such as: How accurate is our documentation? How do we analyze the sheer volume of patients and visits? Where do we start? How do we prioritize? A reactive approach to the explore phase is driven by reimbursement not reflecting the care provided.

Define: The facility begins reviewing their risk adjusted patients to identify which patients do not have accurate RAF Scores. Based on this, the facility will prioritize patients for review to ensure the time spent is most productive. Typically, organizations begin to use Excel to manage the work queues. This can work early in the process, but as the patient volume increases and workflow begins to include other areas of the health system, it becomes problematic as the amount of data is difficult to manage and manual data entry becomes less reliable. The facility typically finds a chronic condition to focus on or a group of physicians to run a pilot test to determine the right people, processes, and tools needed.

Implement: The hospital has moved beyond a pilot test and begins to implement a program where consistent procedures are followed across multiple clinics or provider groups. The team typically grows and the workflow becomes the norm. A cross-training program might exist for their growing team. More sophisticated tools are sought to replace Excel.

Optimize: At this point the hospital has established a program with consistent policies and procedures. Performance is monitored, and they have been able to solve some of the easier issues such as recapturing previously identified HCCs year to year. The next step is to ensure they have captured the chronic conditions for their patients that have not been previously reported. Trends in chronic conditions will be analyzed and compared within their region. Data analytics and reporting become critical at this phase so that the health system can easily prioritize their work.

If you are interested in finding out where you are in the process of managing your risk-adjusted population, take our 3-Minute Risk Adjustment Checkup . You can also download a white paper covering insights for managing HCCs and risk-adjusted populations on our website.

Sharp HealthCare’s CDI Transformation

uasi.marketingit@uasisolutions.com (UASI SOLUTIONS) — Mon, 05 Aug 2024 22:17:04 GMT

Change can be a daunting endeavor. When Pam Stence, Director of CDI for Sharp HealthCare, had a hunch that her CDI program may not be performing as well as it could, she decided to dig deep to find answers. She worked with her executive team and did research into key industry players like Cedars Sinai, Johns Hopkins, and U.S. News and World Report hospital data as a place to start benchmarking and comparing her own program’s data. This led her to the conclusion that she needed to optimize her program and rethink their performance.

Pam knew that she could increase Complication/Comorbid Condition (CC) and Major Complication/Comorbid Condition (MCC) capture rates from 3M but needed to make changes to their CDI staffing plan to get the impact she needed. Over the course of two months, she worked with her internal team to establish a goal of 2.5 cases per hour and review 90% of all DRG payors. Coverage felt like a core issue. She needed the expertise and staff to get the job done. Pam was able to use her research to develop a strong case for the needed changes with her management team in order to bring her vision for her department to life.

Hiring posed an interesting problem and was not something that could be quickly scaled. New hires could take up to a year to be trained and ramp up fully into their work load. Pam recognized that they needed quality resources quickly to hit their goals and would need an external partner. She established a list of mandatories they needed:

A partner – not a vendor
High quality resources
Staff with the right credentials and experience
Training in 3M 360 and Cerner
Responsive
Willing to be flexible to meet needs
Known entity with previous engagement

She turned to UASI for a solution. UASI assessed staffing needs, fully staffed up and scaled production quickly. Sharp was able review 90% of all their DRG payors within 1 year as opposed to the 60% rate the years prior. Currently, they review 98% of DRG payors and 90% of all payors at 48 hours. Sharp would hit $19M in 2023 in query impact, up from $11M the previous fiscal year. These were dollars that could have been left on the table had Pam not acted. Quality scores also improved.

We asked Pam what her advice would be to other teams who recognize that they need to make changes to their CDI programs. She came up with great tips to make digging into change easier.

Develop a strategic partnership with your vendor
Share data and be transparent
Be open to a new process
Look at the benchmark data and be objective on where you stand; reach out for help if you need it
Improve physician engagement, involvement and query responsiveness

5 Reasons Why Rural Hospitals Should Consider a New Coding Approach

uasi.marketingit@uasisolutions.com (UASI SOLUTIONS) — Mon, 05 Aug 2024 22:13:29 GMT

5 Reasons Why Rural Hospitals Should Consider a New Coding Approach

1. The ongoing shortage of experienced coders is hitting your organization.

Knowledgeable, experienced coders have long been in demand – but between the implementation of ICD-10 and the COVID-19 pandemic, the situation has become more complex than ever. Coding has become exceptionally complex – especially in places like CAHs, whose coders must cross-train to work across multiple specialty areas without interruption. And with fewer people than ever enrolling in coder education and certification programs, the shortage shows no signs of subsiding.

Especially in today’s environment of coder scarcity, smart coding service providers employ recruiters dedicated specifically to coding professionals. They will operate at a scale that enables them to pay their coders a high hourly wage without forcing unusually high charges onto their clients. They’ll have programs in place to retain existing staff. And they’ll maintain a pipeline of talent for future needs, as well.

2. Your coders face ever-increasing quality and productivity demands.

As healthcare technology evolves, so does coding complexity – especially in high-risk and specialty areas. Likewise, when healthcare systems acquire physician practices, they often find themselves with new professional fee coding responsibilities that their coders may not have the experience to manage. Then, there’s the question of assuring productivity and quality. When coders fall below expected quality and productivity levels, organizations find themselves with an impossible choice: Keep the coder but risk speed, accuracy, and even compliance issues. Or, terminate the coder and face the consequences of working short-staffed.

An excellent coding partner will have a proven approach for vetting prospective coders. Equally important, they’ll provide continual professional development and testing to keep their coders sharp. That training and education will both reinforce existing processes and bring their coders up to speed with the latest demands of multiple types of healthcare organizations. They’ll conduct quarterly reviews and have specific action plans for consistently maintaining high standards.

Accurate, defensible, compliant coding is essential to the revenue cycle of all healthcare organizations. That level of coding demands experienced, knowledgeable, high-integrity coders. Yet, many organizations – especially Critical Access Hospitals (CAHs) – struggle with this crucial capability.

Outsourced coding isn’t the right solution for every organization. So, how do you know if it’s right for yours? Consider the following five essential reasons to pursue an outsourced solution:

3. Your coding load rises and falls – and it’s costing you money.

Healthcare organizations often struggle with the expense of excess staffing during periods of low demand – whether because they employ extraneous coders during times of low demand or because they spend money on temporary coders in times of high demand. Those temporary coder costs go well beyond their hourly rates, too -- including what it takes to bring their institutional knowledge up to speed, integrate them into the organization, and ensure quality control.

There is significant value in a coding partner who takes the time to learn the ebbs and flows of your coding load and your overall corporate culture. That knowledge enables them to scale up and down with your coding requirement, providing virtually instantaneous coverage when you need it – and keeping you from having to pay for coders when demand is low. They’ll also take the time to understand how your organization and department operate and prepare their coding professionals to fit in seamlessly.

4. You’re located in a rural or underserved urban zone.

Many healthcare organizations require staff to live within their geographic area – even if those staff members are permitted to work remotely. As a result, issues ranging from infrastructure and education quality to safety make it difficult to attract and retain qualified coding talent.

In an outsourced coding partnership, the coders are the partner’s employees, so they may not be bound by your organization’s residency requirements. However, your agreement with them can ensure full coding support, on-site and off-site, wherever you may be.

5. The expenses and stresses of an internal coding department are a burden.

Increasing costs and decreasing reimbursements are challenging virtually every healthcare system. However, when you add in the costs of recruiting, hiring, onboarding, training, continuing education, and retention of an internal coding department, the financial burden can become overwhelming.

When you outsource your coding to the right partner, you don’t spend time, money, and resources on building and maintaining an internal team of coders, ensuring quality, productivity, compliance, and even the software coders must use. The partner takes responsibility for those elements, which reduces your burden significantly.

Many healthcare organizations are struggling with some or all of the challenges that may impede the consistent coding excellence necessary to achieve successful revenues. If yours is one of them, you owe it to your balance sheet to consider the advantages of the right outsourced coding partnership.

Diagnosis Coding for Neoplasms

uasi.marketingit@uasisolutions.com (UASI SOLUTIONS) — Mon, 05 Aug 2024 20:32:51 GMT

The accurate classification and documentation of diseases are key, especially in the case of neoplasms. The importance of precise diagnosis coding cannot be overstated. With advancements in medical knowledge and technology, understanding the intricacies is crucial for healthcare professionals striving to provide optimal care for their patients.

Chronic Kidney Disease

uasi.marketingit@uasisolutions.com (UASI SOLUTIONS) — Mon, 05 Aug 2024 20:25:59 GMT

CKD as defined by NKF KDOQI:

Kidney damage for >3 months defined by structural or functional abnormalities of the kidney that can lead to decreased GFR

• For CKD to be diagnosed, one of the following criteria must be present for >3 months:

GFR <60, or Clinical markers of kidney injury with objective findings such as: Albuminuria, abnormal urine sediment, electrolyte abnormalities due to renal tubular disorders, histological and structural abnormalities, or history of renal transplant

• CKD stage is determined by the stable GFR:

Stage GFR

>90
60-89
3a 45-59; 3b 30-44
15-29
<15

ESRD Dialysis-dependent stage 5

Important note: GFR in stages 1 and 2 is >60 which does not meet the first criterion, so a diagnosis of CKD would require at least one clinical indicator of kidney injury

Provider documentation should be clear if there is a causal relationship related to the CKD to determine the most accurate code assignment.

For example, a patient is admitted with diabetes, hypertension and CKD and the provider links the CKD to the diabetes.

A causal relationship is indicated and denotes the CKD is not related to the hypertension.

Only a code for diabetic CKD would be reported.

Hypertension would be reported separately.

CKD should not be coded as hypertensive if the physician has specifically documented a different cause.

Provider documentation noting only the presence of comorbid conditions and CKD would capture a cause and effect relationship between the conditions.

For example, a patient is admitted with chronic comorbidities noted as diabetes, hypertension and CKD.

A cause and effect relationship are presumed, and the CKD is most likely related to both hypertension and diabetes.

Assign codes:

Type 2 diabetes mellitus with diabetic chronic kidney disease
Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease
Chronic kidney disease, unspecified

Provider documentation should be clear related to a kidney transplant status and CKD.

For example, a patient admitted to the hospital has kidney transplant failure with CKD 4.

Principal diagnosis would be Kidney transplant failure, for complication of the transplanted kidney.
Chronic kidney disease stage 4 would be coded as a secondary diagnosis.
Additional Tips:

Correct documentation of CKD stage is important- stages 4 and 5 without HD are CCs. If the stage is not documented and stable creatinine levels are present, providers should be queried for patients with a GFR < 60.
If the patient’s history presents competing etiologies for the documented CKD (for example-a patient with polycystic kidney disease and hypertension), a query is likely required for accurate code assignment.
The Official Guidelines for Coding and Reporting state that chapter-specific guidelines from Chapter 9 and 14 direct reporting of combination codes r/t CKD, hypertension, and diabetes. The classification presumes a causal relationship between CKD and the conditions of hypertension and heart failure. If the provider indicates the CKD is not related to the hypertension and/or heart failure, the combination code would not be assigned. A code from category N18 should also be assigned for the specific stage of CKD.
The Official Guidelines for Coding and Reporting states that patients with a history of renal transplant should have CKD staged per the eGFR. The presence of CKD is not considered a complication. Both the specific N18 code and the Z94.0 code for kidney transplant status would be assigned.
The providers documentation of CKD G4A3 is synonymous with stage 4 CKD and would code to N18.4 per Coding Clinic First Quarter 2023.

References:

Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2018: page 88.

Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2020: page 35.

Coding Clinic for ICD-10-CM/PCS, First Quarter 2023: page 17.

Prescott, L. & Manz, J. (2020). 2021 ACDIS Pocket Guide. The Essential CDI Resource. HCPro, 323-328.

Pinson, R. & Tang, C., (Jan, 2021). Filtering Out Confusion over Kidney Disease. Retrieved from Filtering Out Confusion Over Kidney Disease | Pinson & Tang (pinsonandtang.com)

Adult Obesity/Morbid Obesity with BMI >35

Mon, 05 Aug 2024 20:17:32 GMT

Obesity vs. Morbid Obesity: ICD-10-CM Coding and Documentation Guidance

Obesity and morbid obesity are always clinically significant and reportable when documented by the provider. (Coding Clinic 4th Quarter 2018 p.77).

Definitions of Obesity and Morbid Obesity

According to the National Institute of Health the definition of morbid obesity is as follows:

being 100 lbs or more above ideal body weight; or
having a BMI of 40 or greater;
having a BMI of 35 or greater with one or more obesity related health conditions such as hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, osteoarthritis, and gastroesophageal reflux disease.

BMI Classifications and Coding Rules

BMI classifications (in kg/m2):
Underweight- BMI <18.5
Optimum range 18.5-24.9
Overweight: BMI 25-29.9
Class I Obesity: BMI 30-34.9
Class II obesity: BMI 35-39.9\
Class III obesity: BMI >40

BMI codes should only be assigned when there is an associated, reportable diagnosis (such as obesity). Do not assign BMI codes during pregnancy. 2024 ICD-10-CM Guidelines (I.C.21.c.3).

Clinical Indicators and Query Example

For example, a patient chart includes clinical indicators:

Anthropometric flowsheet 01/01/23: Height: 167.7 cm., weight: 104 kg., BMI: 36.98
01/01/23 H&P- exam: “abdomen- obese”
Risk Factors: DM II, HTN, hypercholesterolemia
Treatment: daily weight, I&O, 60-75g CHO diet

A query should be considered to clarify the diagnosis of morbid obesity based on a BMI>35 with associated chronic comorbidities such as diabetes and heart disease.

Additional Coding Guidance for Obesity and BMI

BMI codes must be accompanied by a weight-based diagnosis to be captured. BMI is a person’s weight in kilograms divided by height in meters squared. The BMI can be captured from clinicians who are not the patient’s provider such as a nurse, dietitian, or tech. However, the associated weight-based diagnosis must be documented by the patient’s physician. (Official Coding Guidelines, Section I.B.14; Documentation by Clinicians Other than the Patient’s Provider).
If the provider documents overweight without additional documentation to support the clinical significance the code for overweight is not assigned. (Coding Clinic 4th Quarter 2018 p.77).
Comorbidities do not change a diagnosis of obesity to morbid obesity. A query would be warranted if morbid obesity is not documented.
If there is conflicting weight documentation between providers, defer to the attending physician.
Class 3 obesity is synonymous with morbid obesity and is assigned code E66.01. Class 1 and 2 obesity need a query to determine the type or etiology if not specified in the documentation. (Coding Clinic 2 ^nd Quarter 2022 p.9).

Quality and Risk Adjustment Impact

Quality impact:

Obesity is an Elixhauser variable
E66.09, E66.1, E66.8, E66.9
Morbid obesity is an HCC and an Elixhauser variable
E66.01, E66.2
BMI >30 to >70 is an Elixhauser variable and HCC
Z68.30-Z68.45

Additional Clinical Context for Obesity

9% of the US adult population had class III obesity from 2017-2018.
Factors increasing the risk for obesity include genetics, lack of physical activity, lack of sleep, high stress, increased age, female sex, hormone imbalances (hypothyroidism, high cortisol levels), cultural factors, exposure to chemicals such as obesogens, and low socioeconomic status
A waist circumference in women of >35 or >40 inches in males may help to diagnose obesity.
Treatment includes healthy lifestyle changes (exercise, diet), behavioral and psychological therapy, medications, and surgery.
Obesity is associated with higher rates of death related to comorbidities such as diabetes, HTN, HLD, OSA, GERD, certain cancers, and PCOS.

Works Cited:

Bernard, S. P. (2019). Let’s get on the same page when coding BMI and obesity. AAPC Knowledge Center. Available at: https://www.aapc.com

Cleveland Clinic. (2023). Class III obesity (formerly known as morbid obesity): Causes, symptoms, risks & treatment. Available at: https://my.clevelandclinic.org

Abdelaal, M., le Roux, C. W., & Docherty, N. G. (2017). Morbidity and mortality associated with obesity. Annals of Translational Medicine, 5(7), 161. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5452220/

Adverse Reactions to Drugs & Toxins / Poisoning / Underdosing / Toxic Effects

uasi.marketingit@uasisolutions.com (UASI SOLUTIONS) — Mon, 05 Aug 2024 20:10:20 GMT

Adverse Effects vs Poisoning vs Underdosing: ICD-10-CM Coding Guidance

Key Definitions for Adverse Effects, Poisoning, Underdosing, and Toxic Effects

Adverse Effect: occurs when a substance is taken according to direction and a reaction occurs
Poisoning: indicates improper use of medication including combination with alcohol, overdose, wrong drug, wrong dose, or taken in error
Underdosing refers to taking less or discontinuing a medication that is prescribed
Toxic Effects: a reaction, consequence, or effect of a non-medicinal substance such as alcohol, animal venom, or carbon monoxide

Documentation Requirements for Accurate Code Assignment

Provider documentation needs to be clear whether a drug was taken as directed or improperly administered to determine an adverse effect vs. poisoning.

Coding Example: Adverse Effect vs Poisoning (Coumadin)

For example, a patient with a GI bleed due to Coumadin therapy would need clarification if the Coumadin was taken properly or not taken properly.

Taken properly as directed would have an adverse effect – Principal diagnosis is the nature of the adverse effect.
GI bleed is associated with Coumadin therapy, taken properly.
Taken improperly would be poisoning – The principal diagnosis is the poisoning effect from improper coumadin.
GI bleeding is associated with Coumadin therapy, not taken properly
Provider documentation should be clear whether a diagnosis results from a cause/effect of poisoning.

Coding Example: Poisoning and Substance Use (Cocaine)

For example, a patient admitted/discharged with a diagnosis of musculoskeletal chest pain with cocaine use just before the onset of symptoms.

Chest pain associated with cocaine use provides clarity on the etiology of the pain.
Poisoning is the principal diagnosis, and chest pain is the secondary diagnosis.
Provider documentation must be clear whether a diagnosis results from a toxic effect.

Coding Example: Toxic Effects (Spider Bite)

For example, a patient is admitted with right hand cellulitis and documentation in the nurse’s notes reflects patient was bitten by a spider on the right hand the day before admission.

Right-hand cellulitis due to spider bite provides clarity of the cause of the cellulitis.
A toxic effect diagnosis would be the principal diagnosis and cellulitis would be a secondary diagnosis.

Coding Example: Underdosing and Disease Exacerbation

For example, seizure disorder will be principal when a patient is admitted after having a seizure and noted with subtherapeutic Dilantin levels.

Codes for underdosing should never be assigned as principal diagnosis or first listed codes.
The exacerbation or relapse of a medical condition due to under dosing is the principal diagnosis.

Additional ICD-10-CM Coding Tips for Drugs and Substances

Use as many codes as necessary to describe completely all manifestation of the adverse effect, poisoning, underdosing, or toxic effect.

If two or more drugs, medicinal or biological substances are taken, code each individually.

The poisoning codes have an associated intent as their 5th or 6th character (accidental, intentional self-harm, assault and undetermined). If the intent of the poisoning is unknown or unspecified, code the intent as accidental intent. The undetermined intent is only for use if the documentation in the record specifies that the intent cannot be determined.

Documentation of a change in the patient’s condition is not required in order to assign an underdosing code. Documentation that the patient is taking less of a medication than is prescribed or discontinued the prescribed medication is sufficient for code assignment.

If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded too.

If marijuana is legalized for therapeutic/recreational use per state legislature (depending on the documentation in the chart), it is no longer considered an illicit drug. To capture an adverse reaction in this case, it would be coded as poisoning or adverse effect.

Works Cited

Centers for Disease Control and Prevention. (2026). ICD-10-CM Official Guidelines for Coding and Reporting. Available at: https://www.cdc.gov/nchs/icd/icd10cm.htm

American Hospital Association. (2026). Poisoning, adverse effects, and underdosing coding guidance. AHA Coding Clinic for ICD-10-CM/PCS.

Tips to engage your remote HIM employees

uasi.marketingit@uasisolutions.com (UASI SOLUTIONS) — Mon, 05 Aug 2024 20:04:55 GMT

How to Keep Remote Healthcare Teams Engaged and Connected

It’s not new news that work as we knew it has changed dramatically over the past few years with more employees working remotely than ever before. While this is a newer phenomenon for many HIM employees, at UASI we’ve been working this way for over 20 years. In order to recruit and retain the best in the field, and cut down on travel hassle for our teams and costs for our clients, we built our remote coding services practice 23 years ago. Our success operating this way led us to quickly adopt remote working for our Revenue Integrity, CDI, Audit and Coding Review and consulting teams as well. This has enabled us to find the best talent no matter which zip code he/she lives in over the years.

Working remotely can be lonely and people can feel isolated, so it’s important to engage your staff regularly and in various ways. Though there are countless articles and blog posts about working remotely successfully, it’s still a struggle for many. Regardless of having 20+ years of experience operating this way, it never hurts to remind ourselves what works, so we wanted to share a few tips.

Practical Ways to Engage Remote HIM and Coding Teams

Routinely schedule calls with your team members to check in and see how they personally are doing and how the work is going. Make sure to personalize the call and ask if goals are being met and if there are issues preventing their success or milestones to celebrate.

Send emails consistently that not only check in on people, but also share something fun and/or educational such as:

Industry hot topics and/or education
Fun facts for that month or week
Celebrations such as birthdays, births, graduations, work anniversaries
Congratulations on obtaining new credentials or a personal milestone

Make Department meetings fun and educational. After providing an overview of the team performance and updates, ask a few people to share something about themselves and/or have a few team members take turns presenting an educational topic briefly. This enables them to work together on something, work on something different than their day-to-day responsibilities and educate the team at the same time. You can even play online games to get to know each other or just to have fun. Our teams play trivia games, bingo, and even industry-related word searches. It is a simple way to engage people and creates opportunities to bond with one another.

Share good news with the team when someone is successful or gets a compliment from a client. This way the whole team can share in the success and appreciate the fact that they are working with smart, successful teammates. You can even set up a system to allow staff to nominate each other for great work
or achievements for anyone in the company.

Building a Culture of Connection and Recognition

Conduct remote social activities. Some successes we’ve had are creating a social media “breakroom” for
staff only, creating holiday cookbooks or even gift exchanges where you can celebrate together virtually.
Remote gift exchanges do take a little coordination, but how fun is it to get a “surprise” in the mail?

Invite individuals to participate in health-related challenges, such as step challenges, mindfulness
meditation or some type of self-care. These are important because let’s face it, we sit all day. If we can
help our teams stay active, they will be healthier and happier.

At UASI we frequently have these types of challenges frequently with incentives to participate. In addition, one of our senior leaders conducts a weekly mindfulness mediation session. It’s a great way to break up the day and feel energized for the rest of the week.

Encouraging Feedback and Continuous Improvement

Always, always encourage staff to share ideas, issues and solutions. Your employees have the bird’s eye view of their jobs and many have great insight and suggestions on ways to improve processes or tools. At UASI we do this regularly in our team meetings, but we also have a corporate Innovation Program where anyone can submit ideas for improvement.

These ideas are evaluated by a small committee on a regular basis and then the person submitting gets feedback on the idea. If we decide to pursue the idea, many times the submitter participates in crafting the solution. If we decide to not take action at the moment, the submitter is given the rationale. In this way, everyone knows their ideas are valued whether or not we decide to implement them.

Your people are what make your company great. Working remotely can be lonely and people can feel isolated so it is important to ensure you have a good engagement program in place. Keep it up or get one or more of these started. Today. Don’t delay.

Pediatric Respiratory Failure

uasi.marketingit@uasisolutions.com (UASI SOLUTIONS) — Mon, 05 Aug 2024 19:54:41 GMT

Respiratory failure: a syndrome in which the respiratory system fails in one or both of the functions of gas exchange, which are oxygenation and carbon dioxide elimination. It can be classified as hypoxemic (type 1), hypercapnic (type 2), or a combination of both.

Respiratory failure can be acute or chronic. The etiology of acute respiratory failure is often determined to be pneumonia, bronchiolitis, croup, trauma, or exacerbation of a chronic condition such as asthma.

Chronic respiratory failure: a condition in which the inability to effectively exchange carbon dioxide and oxygen results in chronically low oxygen levels or chronically high carbon dioxide levels. Usually the underlying etiology is chronic lung disease such as cystic fibrosis, neuromuscular disorders, or muscular dystrophy. Diagnosis requires the use of home oxygen or ventilator support, or having baseline SaO2 < 88% on room air or pCO2 > 50 with normal pH.
Acute respiratory distress syndrome (ARDS): often considered the end stage of acute respiratory failure, occurring when fluid builds up in the alveoli which prevents the lungs from filling with enough air. This leads to less oxygen reaching the bloodstream and organs, reducing organ function. ARDS patients have a moderate to severe impairment of oxygenation as defined by the ratio of partial pressure arterial oxygen and fraction of inspired oxygen (PaO2/FiO2). Chest imaging exhibits bilateral opacities/pulmonary edema not explained by cardiac failure or fluid overload.

Diagnostic Criteria for Acute Respiratory Failure in Pediatric Patients

Pediatric patients often present differently than adults and can also decompensate more quickly. Children may present with the following:
Lethargy or irritability
Appear anxious or demonstrate inability to concentrate
May prefer positioning to aid in breathing (i.e sitting up, leaning chest/head forward)
Mouth breathing, drooling
Interrupted feeding and diet patterns
Generally, oxygen saturation <88% on room air is supportive of acute hypoxemic respiratory failure. ABGs are rarely measured when assessing children’s respiratory function. However, diagnostic ABG levels include:
PaO2 of < 60 mmHg on room air
Acute increase in pCO2 of 10-15 mmHg
pH decreasing to 7.32 or less
PaO2 / FiO2 (PF) ratio of < 200 or < 300
Intubation/mechanical ventilation is not required to support the presence of acute respiratory failure. An acute respiratory condition and any of the following treatments may support the presence of acute respiratory failure:
Supplemental oxygen with FiO2 ≥ 0.30–0.35 to maintain SpO2 ≥ 90%
Any level of high-flow nasal cannula
Any level of nasal continuous positive airway pressure (nCPAP) or nasal bilevel positive airway pressure (BiPAP) (except for obstructive sleep apnea)
Provider documentation often describes the patient’s symptoms and assessment without stating the words “acute respiratory failure.” If clinical indicators support the presence of acute respiratory failure, a query should be sent.
For example, “acute respiratory distress”, “acute exacerbation”, “respiratory insufficiency”, “respiratory acidosis” are frequently used terms that may not capture the patient’s true complexity.
Providers frequently use templated notes that are copied/pasted into subsequent notes. This is a great opportunity for CDI to provide education on customizing these templates.
Templated notes often have statements such as “no acute distress”, and “normal appearance” which can suggest that the patient did not have respiratory failure.

Additional Tips:

• Chapter-specific coding guidelines (particularly with newborns) that provide sequencing direction take precedence when determining the principal diagnosis.

• A code from subcategory J96.0, Acute respiratory failure, or subcategory J96.2, Acute and chronic respiratory failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital.

• Although acute respiratory failure always has an underlying cause, do not default to the etiology as the principal diagnosis. The circumstances of the admission must be considered. Respiratory failure may be listed as either the principal or a secondary diagnosis.

• For acute respiratory failure due to COVID-19, assign code U07.1, COVID-19, followed by code J96.0-, Acute respiratory failure.

• If the documentation is not clear as to whether acute respiratory failure and other conditions are equally responsible for occasioning the admission, query the provider for clarification.

• Common respiratory failure risk factors to look out for in pediatric patients include: young age, premature birth, immunodeficiency, chronic pulmonary/cardiac/neuromuscular diseases, anatomic abnormalities, cough/rhinorrhea/other URI symptoms, and lack of immunizations.

• Other conditions that are not pulmonary in nature which may lead to acute respiratory failure include: status epilepticus leading to encephalopathy and decreased respiratory drive, a traumatic head injury or anoxic brain injury that stops respiratory drive, and septic shock.

References:

Pediatric Acute Lung Injury Consensus Conference Group. (2015). Pediatric acute respiratory distress syndrome: Consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatric Critical Care Medicine, 16(5), 428–439. https://doi.org/10.1097/PCC.0000000000000350

Springer, S. C. (2012, December 5). Pediatric respiratory failure. Medscape. https://emedicine.medscape.com/article/908172-overview

Savage, L. (2017). Pediatric CDI Building Blocks for Success (pp. 64–71). HCPro.

Navigating Healthcare Excellence with UASI

Acute Hospital Care at Home: CMS Signals a Shift in Risk Adjustment and Payment Models

Acute Hospital Care at Home: CMS Signals a Shift in Risk Adjustment and Payment Models

Hospital-at-Home, CMS Evidence, and a Quiet Signal on Risk Capture

CMS Findings on Acute Hospital Care at Home Outcomes

Patient Complexity and Risk Adjustment Factor Scores in Fee-for-Service Medicare

How CMS Uses HCC Coding to Evaluate Care Delivery Models

What This Means for Medicare Fee-for-Service Payment Models

The Expanding Role of Risk Adjustment Across Medicare Programs

﻿ Additional Resources

Pregnancy ICD-10 Coding Refresher: Chapter 15 Guidelines and Trimester Selection

Pregnancy ICD-10 Coding Refresher: Chapter 15 Guidelines and Trimester Selection

Understanding Chapter 15: Pregnancy, Childbirth, and the Puerperium

Using the ICD-10-CM Tabular for Pregnancy Code Selection

Determining Trimester Based on Weeks of Gestation

Pregnancy Coding Example: Epilepsy in the Second Trimester

Works Cited

Welcome Cindy Smith

UASI Names Cindy Smith as Managing Consultant, Managed Services & Strategy

How to Code Thyroid Eye Disease (TED) with New ICD-10-CM Codes

How to Code Thyroid Eye Disease (TED) with New ICD-10-CM Codes

What Is Thyroid Eye Disease (TED)?

New ICD-10-CM Codes for Thyroid Eye Disease

Treatment Considerations for Thyroid Eye Disease

Coding Example & Reminder for Thyroid Eye Disease

Works Cited:

Hypercholesterolemia: When to Assign E78.0 vs Other Lipid Disorder Codes

Hypercholesterolemia ICD-10 Coding: When to Assign E78.0 vs Other Lipid Disorder Codes

Understanding Hypercholesterolemia in ICD-10-CM Coding

ICD-10-CM Code Assignment for Hypercholesterolemia

Differentiating Hypercholesterolemia from Other Lipid Disorders

Coding Tips for Accurate Assignment

Common Coding Pitfalls

FY 2026 Coding Considerations

Works Cited

Encephalopathy Coding: Types, Guidelines, and Documentation Tips

Encephalopathy ICD-10-CM Coding: Types, Guidelines, and Documentation Tips

Overview of Encephalopathy

Types of Encephalopathy and ICD-10-CM Codes

Documentation Requirements for Accurate Coding

Coding and CDI Tips for Encephalopathy

Clinical Indicators Supporting Encephalopathy

Query Opportunities for Encephalopathy

FY 2026 Coding Considerations

Works Cited

Non-Infectious SIRS: Documentation and Coding Considerations

Non-Infectious SIRS: Documentation and Coding Considerations

Clinical Indicators of Non-Infectious SIRS

Common Conditions Associated With Non-Infectious SIRS

ICD-10-CM Coding for Non-Infectious SIRS

Acute Organ Dysfunction Considerations

CDI Query Prompt for SIRS Clarification

﻿

Works Cited

When to Query for Acute Respiratory Failure with Hypoxia (J96.01)

When to Query for Acute Respiratory Failure with Hypoxia (J96.01)

Acute Respiratory Failure with Hypoxia: What Coders Need to Look For

Understanding J96.01 and Related ICD-10-CM Codes

Clinical Picture: When Hypoxia Becomes Respiratory Failure

Documentation Gaps That Create Missed Coding Opportunities

CDI Tip: Watch for Escalation in Respiratory Support

Why This Diagnosis Matters

FY 2026 Coding Considerations

Query Opportunity: Clarifying Acute Respiratory Failure with Hypoxia

Works Cited

How MASLD and MASH Translate to ICD-10-CM Coding

MASLD and MASH vs NAFLD and NASH: ICD-10-CM Coding Guidance

Overview of Evolving Liver Disease Terminology

MASLD vs NAFLD: Coding Considerations

MASH vs NASH: Coding Considerations

Key ICD-10-CM Coding Takeaways

Works Cited

AAOLCA Transconal Unroofing

ICD-10-PCS Coding for AAOLCA Transconal Unroofing Procedure

Overview of AAOLCA and Transseptal Coronary Anatomy

What is AAOLCA?

Clinical Risks Associated with AAOLCA

Procedure Overview: Najm Transconal Unroofing Technique

ICD-10-PCS Coding Principles for Transconal Unroofing

Procedure Components and ICD-10-PCS Code Assignment

Additional Resources