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

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. 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, 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. Z59.00, 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 (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. Summary 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.  References Baggett, T. (2023). Healthcare of people experiencing homelessness in the United States. UpToDate. Retrieved on December 31, 2024 from https://www.uptodate.com/contents/health-care-of-people-experiencing-homelessness-in-the-united-states?search=homelessness&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1 Hooper, D. (2024). Extended-spectrum beta-lactamases. UpToDate. Retrieved on December 31, 2024 from https://www.uptodate.com/contents/extended-spectrum-beta-lactamases?search=antimicrobial%20resistance&source=search_result&selectedTitle=7%7E150&usage_type=default&display_rank=7 MD Anderson Cancer Center. (2025). Stem Cell (Bone Marrow) Transplants. mdanderson.org . Negrin, R. (2024). Early Complications of hematopoietic cell transplantation. UpToDate. Retrieved on January 14, 2025 from https://www.uptodate.com/contents/early-complications-of-hematopoietic-cell-transplantation?search=bone%20marrow%20transplant%20complications&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1 Pinson, R., Tang, C. (2024). The CDI Pocket Guide by Pinson and Tang. www.cdiplus.com .

Definition 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. Diagnostics Stages and Definitions (NPIAP; www.npiap.com ): 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 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 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 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 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 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)  References Centers for Medicare and Medicaid. (2023). Announcement of Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. CMS Edsberg, L. E., et al. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System. J Wound Ostomy Continence Nurs, 43(6), 585-597. doi:10.1097/won.0000000000000281 Tang, C., Pinson, R. (2024). CDI Pocket Guide by Pinson and Tang. CDI Plus Zaidi SRH, Sharma S. (2024). Pressure Ulcer. In StatPearls [Internet]. NCBI

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

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

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

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

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?

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.