Brandon Losacker • February 13, 2025

UASI Compliance Analysis - Outpatient Documentation and Coding Issues

DOWNLOAD FULL ARTICLE HERE!

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. 

UASI Suggested Compliance Activities for this Initiative

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

Acute Kidney Injury (AKI)

By Katie Curry • October 20, 2025
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. 1. 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”). 2. 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 3. 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 4. 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. References: AHA Coding Clinic, Third Quarter 2025, p. 22 AHA Coding Clinic, Fourth Quarter 2022, p. 33 Centers for Medicare and Medicaid Services. (2025). Official Guidelines for Coding and Reporting. 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. www.acdis.org

Reporting of Firearm Injury Intent

By Katie Curry • September 30, 2025
CDI Tip: Capturing 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): _______________________

Ventricular Standstill

By Katie Curry • September 22, 2025
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.

CDI TIP: Neuro Storm

By Katie Curry • September 7, 2025
What does it mean when “neurostorming” is documented? “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. What are the risk factors for PSH? Traumatic brain injury (TBI) Hypoxic ischemic injury What are the clinical indicators of PSH? 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 How is PSH treated? Reducing stimulation Managing hyperthermia and hyperventilation Medications IV Morphine Gabapentin Beta blockers Baclofen Precedex infusion Dantrolene Coding and CDI considerations for the documentation of “neurostorming” 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. References: American Hospital Association (AHA). ICD-10-CM Coding Clinic, Second Quarter 2025, p. 4. Available from: AHA Coding Clinic Centers for Medicare & Medicaid Services (CMS). (2025). ICD-10-CM Official Guidelines for Coding and Reporting. Available from: CMS ICD-10-CM Guidelines Rabinstein, A. (2024). Paroxysmal sympathetic hyperactivity. UpToDate. Available from: UpToDate – Paroxysmal sympathetic hyperactivity

New ICD-10-CM Code E11.A: Type II diabetes mellitus without complications in remission

By Katie Curry • August 7, 2025
Background: 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 Guidelines for Coding and Reporting 2026: 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 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: ________________ References: American Diabetes Association. Standards of Care in Diabetes—2024: Section 2 and Section 6. 2024. Section 2: https://pubmed.ncbi.nlm.nih.gov/38078586/ Full guidelines: https://professional.diabetes.org/standards-of-care Section 6: https://diabetesjournals.org/care/article/47/Supplement_1/S111/153951/6-Glycemic-Goals-and-Hypoglycemia-Standards-of PMC version: https://pmc.ncbi.nlm.nih.gov/articles/PMC10725808/ Buse, John B., et al. “How Do We Define Cure of Diabetes?” Diabetes Care, vol. 32, no. 11, 2009, pp. 2133–2135. DOI: 10.2337/dc09-9036. PubMed: https://pubmed.ncbi.nlm.nih.gov/19875608/ PMC: https://pmc.ncbi.nlm.nih.gov/articles/PMC2768219/ Centers for Medicare & Medicaid Services. ICD-10-CM Official Guidelines for Coding and Reporting 2026. 2025. https://www.cms.gov Centers for Medicare & Medicaid Services. IPPS 2026 Proposed Final Rule. 2025. https://www.cms.gov

Neonatal Encephalopathy

By Katie Curry • July 9, 2025
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. 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 Query Example: 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): __________

CDI Tip: Tumor Lysis Syndrome

By Katie Curry • May 12, 2025
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.

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)

By Brandon Losacker • April 17, 2025
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. 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: Schwartz and Bartter Clinical Framework 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 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 Suggestive 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 Documentation Tips 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. References Centers for Medicare and Medicaid Services. (2024). ICD-10-CM Official Coding Guidelines. cms.gov Pinson, R., & Tang, C. (2024). The CDI Pocket Guide. cdiplus.com Prescott, L., & Manz, J. (2024). ACDIS CDI Pocket Guide. acdispro.com Sterns, R. (2024). Pathophysiology and etiology of SIADH. UpToDate. 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

By Brandon Losacker • April 17, 2025
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 .
Provider Queries 101

Provider Queries 101 – A Quick Guide to Help Providers Understand the Purpose & Benefits of Queries

By Brandon Losacker • March 25, 2025
The question we hear most often: “What is this query for and why do I have to answer it?” We often incorrectly assume that because a physician is an expert in medical procedures, they are also an expert in documenting those procedures. Physicians are responsible for the care and treatment of millions of patients every single day who put their lives, quite literally, in the physician’s hands. However, to consistently maintain and improve upon safety and effectiveness standards, the system relies on more than just the skill and actions of the provider – it also relies on accurate and comprehensive clinical documentation. Precise and comprehensive clinical documentation is essential for: • Appropriate Reimbursement • Quality Metrics and Reporting • Consistency of Treatment Plans  Central to this process is the physician query, a tool employed by medical coders and Clinical Documentation Integrity (CDI) professionals to clarify ambiguities, inconsistencies, or gaps in medical records. For providers, understanding why a query is in their inbox could help change a query from a source of frustration into an opportunity for patient safety and appropriate reimbursement.
Show More