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.

Presented below is an analysis of new and ongoing initiatives under the Office of the Inspector General (OIG) Work Plan [1] and Centers for Medicare & Medicaid Services (CMS) approved Recovery Audit Contractor (RAC) reviews [2] as of January 2025. The focus is on inpatient initiatives related to HIM coding and documentation requirements and is not intended to review every active work plan item. For each relevant initiative, a summary of the compliance concern, the month and year of the initiative and related coding and documentation requirements is included. More importantly, for each inpatient initiative presented, UASI has included specific suggested compliance activities to assist our clients with their ongoing compliance efforts. The Office of the Inspector General’s (OIG) work plan process is dynamic and changes are made throughout the year. This allows the OIG to meet priorities and react to emerging issues. The OIG work plan website is updated monthly. While there are many topics on the work plan, the majority do not apply to coding and documentation. The information below includes an analysis of the following active inpatient topics: · Medicaid Inpatient Hospital Claims with Severe Malnutrition (OIG) · CMS Oversight of the Two-Midnight Rule for Inpatient Admissions (OIG) · Inpatient Hospital MS - DRG Coding Validation (RAC) Medicaid Inpatient Hospital Claims with Severe Malnutrition, Revised 2024 Severe Malnutrition remains an active item on the OIG workplan. Malnutrition can result from treatment of another condition, inadequate treatment or neglect, or general deterioration of a patient’s health. Hospitals are allowed to bill for treatment of malnutrition based on the severity of the condition (mild, moderate, or severe) and whether it affects patient care. Severe malnutrition is classified as a major complication or comorbidity (MCC). Adding an MCC to a claim may result in higher reimbursement as the claim is coded to a higher MS-DRG. Criteria related to severe malnutrition diagnosis and identification of severity is based on two main sets of criteria: · First, the American Society of Parenteral and Enteral Nutrition (ASPEN). o ASPEN criteria include three situations where malnutrition can occur, including: § 1) Acute illness/injury present for less than 3 months; § 2) Chronic illness present for 3 months or longer; § 3) Social and environmental circumstances limiting access or ability to self-care. o In each of these situations, ASPEN criteria has specific measurement related to energy intake, weight loss, muscle mass loss, body fat loss, edema, and reduced grip strength. · The second criteria in the Global Leadership Initiative on Malnutrition (GLIM). o The GLIM criteria include three phenotypical criteria of weight loss, low BMI, and reduced muscle mass as well as two etiological criteria of reduced food intake or absorption, and increased disease burden or inflammation. Documentation of severe malnutrition, as supported by either ASPEN and GLIM criteria, must also be supported by the treatment plan addressing the underlying etiology and continued treatment beyond the acute care setting. UASI Suggested Compliance Activities · Establish CDI and coding policies related to the use of either ASPEN or GLIM criteria in evaluating the documentation of malnutrition. · Provider education · Develop malnutrition education processes for providers with an emphasis on documentation of the appropriate malnutrition criteria. · Provide ongoing and updated education as identified in documentation audits. · Develop an audit plan · Consider a second-level review process for evaluation of malnutrition documentation, prior to release of the claim. · Establish an audit plan for concurrent and/or retrospective audits for a malnutrition diagnosis. CMS Oversight of the Two-Midnight Rule for Inpatient Admissions, Revised 2024 Prior OIG audits identified millions of dollars in overpayments for inpatient claims with short lengths of stay. Instead of billing the stays as inpatient claims, they should have been billed as outpatient claims, which usually results in a lower payment. To reduce inpatient admission errors, CMS implemented the Two-Midnight Rule in fiscal year 2014. Under the Two-Midnight Rule, CMS generally considered it inappropriate to receive payment under the inpatient prospective payment system for stays not expected to span at least two midnights. The only procedures excluded from the rule were newly initiated mechanical ventilation and any procedures appearing on the Inpatient Only List. Revisions were made to the Two-Midnight Rule after its implementation. OIG plans to audit hospital inpatient claims after the implementation of and revisions to the Two-Midnight Rule to determine whether inpatient claims with short lengths of stay were incorrectly billed as inpatient and should have been billed as outpatient or outpatient with observation. OIG also plans to review policies and procedures for enforcing the Two-Midnight Rule at the administrative level and contractor level. While OIG previously stated that it would not audit short stays after October 1, 2013, this serves as notification that the OIG will begin auditing short stay claims again, and when appropriate, recommend overpayment collections. When a Medicare beneficiary arrives at a hospital in need of medical or surgical care, the physician or other qualified practitioner must decide whether to admit the beneficiary as an inpatient or treat him or her as an outpatient. These decisions have significant implications for hospital payment as not all care provided in a hospital setting is appropriate for inpatient services. Beginning October 1, 2013, CMS adopted the Two-Midnight rule for admissions. This rule established Medicare payment policy regarding the benchmark criteria to use when determining whether inpatient admission is reasonable and necessary. In general, the original Two-Midnight rule states: · Inpatient admissions would generally be payable if the admitting practitioner expected the patient to require a hospital stay that crossed two midnights and the medical record supported that reasonable expectation. The rule was revised in 2016 to permit greater flexibility for determining when an admission that does not meet the benchmark should nonetheless be payable as an inpatient encounter. · Medicare Part A payment is generally not appropriate for hospital stays expected to last less than two midnights. · The documentation in the medical record must support that an inpatient admission is medically necessary. The most recent update to the CMS Two-Midnight Rule occurred in April 2023, when CMS finalized the rule clarifying that Medicare Advantage (MA) plans must also adhere to the Two-Midnight Rule. UASI Suggested Compliance Activities · Collaborate with utilization review (UR) or case management (CM) for potential two- midnight rule issues · If concurrent review processes are in place, review orders to ensure correct patient placement and involve UR as needed Inpatient Hospital MS-DRG Coding Validation, February 2017 This topic remains on the UASI analysis as it is still an active RAC audit topic and there are ongoing audits related to MS-DRG Coding Validation. The background associated with this ongoing audit is noted below. The OIG analyzed paid Medicare Part A claims for inpatient hospital stays from FY 2014 through FY 2019 and identified trends in hospital billing and Medicare payments for stays at the highest MS-DRG severity level. The number of stays at the highest severity level increased almost 20 percent from FY 2014 through FY 2019, ultimately accounting for nearly half of all Medicare spending on inpatient hospital stays. The number of stays billed at each of the other severity levels decreased. At the same time, the average length of stay decreased for stays at the highest severity level, while the average length of all stays remained largely the same. Specifically, nearly a third of these stays lasted a particularly short amount of time and over half of the stays billed at the highest severity level had only one diagnosis qualifying them for payment at that level. Shorter stays are not inherently problematic, but the number of these stays raises questions about the accuracy and appropriateness of the complications billed by the hospital. Although the complications billed suggest sicker beneficiaries, the shorter lengths of stay point to beneficiaries who are less sick. Excluded from this analysis are certain stays that could be expected to be shorter, such as stays during which the beneficiary died. Furthermore, over half of the stays billed at the highest severity level in FY 2019 (54%) reached that level because of just one diagnosis. In total, nearly 2 million stays had just 1 diagnosis (i.e., 1 major complication/comorbidity) that qualified the stay for the highest severity level. The rest of the submitted diagnoses for these stays were either minor complications or not complications. As a result of this analysis, CMS continues to conduct targeted reviews of MS-DRGs and hospital stays that are vulnerable to up-coding (i.e., those that are billed at the highest severity level) and the hospitals that frequently bill for them. Specifically, CMS targets stays at the highest severity level with certain characteristics, such as those that are particularly short lengths of stay or that have only one major complication. CMS also focuses on MS-DRGs that have a high proportion of stays with these characteristics and on the hospitals that frequently bill them. CMS’s RACs currently conduct coding validation reviews that incorporate some of these targeting strategies. [7] In evaluating current audit plans, consider focusing on short stays, especially those with a single CC or MCC or a complex principal diagnosis (e.g., Sepsis, AKI, ARF). UASI also suggests targeting some of the following MS-DRGs for audit depending on your case mix and volume: · MS-DRGs 064 – 066 Intracranial Hemorrhage or Cerebral Infarction · MS-DRGs 193 – 195 Simple Pneumonia and Pleurisy · MS-DRGs 280 – 282 Acute MI Discharged Alive · MS-DRGs 291 – 293 Heart Failure and Shock · MS-DRGs 308 – 310 Cardiac Arrhythmias and Conduction Disorders · MS-DRGs 377 – 379 Gastrointestinal Hemorrhage · MS-DRGs 637 – 639 Diabetes · MS-DRGs 689 – 690 Kidney & Urinary Tract Infections · MS-DRGs 870 – 872 Septicemia or Severe Sepsis · MS-DRGs 981 – 983 Extensive OR Procedures Unrelated to Principal Diagnosis UASI Suggested Compliance Activities · Select targeted MS-DRGs · Evaluate the data for the top 20-25 MS-DRGs and review for any of the above indicators plus any additional MS-DRGs with high volume. · Review the most recent PEPPER reports for MS-DRGs that may be at risk of improper payment. [8] · Establish a prioritized list of MS-DRGs for review. If possible, review cases with short lengths of stay and one MCC/CC. · Develop an audit plan · Establish an audit plan for concurrent and/or retrospective audits. · Retrospective audits can be conducted in part or wholly by incorporating selected MS-DRGs into your audit plan. Problem MS-DRGs can then be incorporated into a concurrent review work queue, if warranted. · Concurrent coding audits should be limited in scope to address specific areas impacting quality reporting and reimbursement. Timeliness is critical as these accounts are held for additional review prior to releasing the bill. Turnaround time to release cases should be short, 24 to 48 hours, to minimize the impact to DNFB (discharged not final billed) daily/weekly goals. · Audits can be conducted either internally or externally. Internal audits should be conducted based on the availability of staff with appropriate technical expertise (in coding and clinical documentation) and proficiency in communicating feedback through written reports and educational sessions. · Determine the audit scope, considering opportunities for cross-departmental collaboration to address multiple risk factors. For example, clinical documentation improvement (CDI) staff may collaborate with coding staff to conduct an audit on sepsis DRGs, addressing both coding and clinical documentation compliance perspectives. · At a minimum inpatient audit should measure and validate the following: · Accurate identification of principal and secondary diagnosis and procedure codes in accordance with official and facility-specific coding guidelines · Accurate MS-DRG or APR-DRG assignment · Accurate POA indicator assigned for all non-exempt diagnosis codes · Accurate Discharge Disposition assignment · Develop corrective action plans, including physician and coder education, based on audit findings. End Notes: 1. OIG Work Plan: https://oig.hhs.gov/reports-and-publications/workplan/index.asp 2. CMS, Approved RAC Topics, last revised 12/01/2024, accessed on January 14, 2025. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics 3. CMS Reminds Hospitals to Use Severe Malnutrition Codes Correctly. October 17, 2023. Article Detail - JF Part A - Noridian 4. Fact Sheet: Two-Midnight Rule; Oct 30, 2015. Fact Sheet: Two-Midnight Rule | CMS

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

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.

The Rising Challenge of Healthcare Denials Healthcare denials are increasing at an alarming rate, creating significant challenges for providers. According to the 2023 Change Healthcare Denials Index, denial rates have risen to 10-15% , up from 6-10% a decade ago. This trend places a strain on revenue cycles, as denials now account for 3-5% of net patient revenue and cost $25 to $50 per claim to rework. For larger health systems, this translates to millions in lost revenue annually . Denials often stem from: Eligibility issues Coding errors Incomplete documentation Untimely filing Duplicate claims Non-covered services These issues delay reimbursements, increase administrative costs, and disrupt cash flow—especially for smaller practices. Why Are Denials Increasing? Several key factors are driving the rise in healthcare denials: 1. Stricter Payer Requirements Payers are enforcing more rigorous guidelines, including prior authorization , detailed medical necessity documentation , and precise coding accuracy . Automated claim review systems are flagging and denying claims at an increasing rate. 2. Regulatory Complexity Frequent updates to ICD-10 and CPT coding standards , along with policies like the No Surprises Act , add administrative burdens that increase the chance of claim processing errors. 3. Workforce Shortages Staffing shortages and turnover in coding and billing departments lead to backlogs and mistakes. Many organizations still rely on outdated systems , lacking AI-powered claim scrubbing or predictive analytics . 4. High-Deductible Health Plans (HDHPs) As more financial responsibility shifts to patients, eligibility verification challenges and higher patient payment denials have become prevalent. Strategies to Reduce Healthcare Denials To mitigate the impact of rising denials, organizations can implement the following data-driven strategies : 1. Strengthen Front-End Processes Verify eligibility and obtain prior authorizations early Ensure accurate patient information collection 2. Improve Coding and Documentation Invest in staff training and clinical documentation improvement (CDI) programs Utilize computer-assisted coding (CAC) tools 3. Leverage Technology Implement AI-powered claim scrubbing Use predictive analytics and automated denial management workflows 4. Monitor Denial Data Track denial rates by payer and reason Establish key performance indicators (KPIs) and conduct regular audits 5. Foster Collaboration Break down silos between revenue cycle teams Create cross-functional groups to address root causes 6. Engage Payers Build strong relationships with payers Negotiate clearer contract terms and resolve disputes efficiently 7. Enhance Patient Communication Educate patients about their financial responsibilities upfront Provide transparent billing statements and assistance with resolving denied claims The Future of Denial Management As healthcare complexity grows, denial rates are likely to continue rising . However, emerging technologies like AI, automation, and enhanced price transparency tools offer hope for reducing denials. Regulatory reforms aimed at simplifying billing processes could further alleviate the burden.  By adopting proactive denial management strategies , investing in technology , and improving internal processes , providers can minimize denials and strengthen their revenue cycles —ensuring long-term financial sustainability and better patient care . Need Help Reducing Denials? UASI offers expert support in denial management and process optimization . Our tailored solutions help reduce denials, improve cash flow, and safeguard your organization's financial health. 📩 Get in Touch: info@uasisolutions.com 🌐 Learn More: www.uasisolutions.com

Balancing Financial Adjustments and Patient Care Amidst Recent Cuts to the Federal Navigator Program On February 14, CMS released a statement announcing cuts to the Federal Navigator Program . These cuts highlight the Trump administration's broader efforts to reduce federal spending on healthcare programs, which will negatively affect patient care and the financial stability of healthcare systems across the country. The CMS Federal Navigator Program is an initiative designed to aid individuals seeking health insurance coverage through the Health Insurance Marketplace through Federally-Facilitated Exchanges (FFEs). Navigators offer free, unbiased help with understanding healthcare options, applying for coverage, and understanding eligibility for financial assistance. This program aims to improve access to health insurance and help consumers make informed decisions about their healthcare options. Revenue cycle leaders will need to adapt to the changes in enrollment patterns and understand the broader impact on reimbursement models while prioritizing access to free and affordable healthcare. Reduced Navigator funding could lead to fewer enrollments in health plans through the FFEs, affecting the number of patients covered by marketplace insurance and altering payer mix. This shift may require mid-revenue cycle leaders to closely monitor enrollment patterns and adjust revenue projections. While lower premiums might benefit individuals without subsidies, those relying on subsidies could face higher out-of-pocket costs, impacting their ability to afford care. Healthcare providers will need to adapt billing and collections strategies to account for fluctuations in premiums and subsidies, while also managing potential changes in reimbursement rates. To navigate these challenges, providers may need to invest in patient education, outreach, and additional support staff to assist with the enrollment process and handle increased claims-related inquiries. The Consequences of Funding Cuts for Low Income Families In addition, the recent reduction in funding for the ACA Navigator program has several implications for low-income families, particularly those who rely on the assistance Navigators provide to access affordable health insurance. The reduction in funding for the Navigator program will make it more difficult for low-income families to access enrollment assistance, creating barriers that could result in missed opportunities or coverage gaps. While some individuals may benefit from lower premiums, those relying on subsidies will likely face challenges navigating changes in the marketplace, which could lead to confusion and increased out-of-pocket costs if they select the wrong plan. Without the personalized support Navigators provide, families may turn to less effective resources, exacerbating stress and potentially worsening health disparities, ultimately impacting long-term health equity and outcomes for low-income individuals. Mid-revenue cycle leaders can take proactive steps to prepare for the changes in the ACA Navigator program while ensuring that patient care for low-income households remains a priority. 

Presented below is an analysis of new and ongoing initiatives under the Office of the Inspector General (OIG) Work Plan [1] and Centers for Medicare & Medicaid Services (CMS) approved Recovery Audit Contractor (RAC) reviews [2] as of January 2025. The focus is on inpatient initiatives related to HIM coding and documentation requirements and is not intended to review every active work plan item. For each relevant initiative, a summary of the compliance concern, the month and year of the initiative and related coding and documentation requirements is included. More importantly, for each inpatient initiative presented, UASI has included specific suggested compliance activities to assist our clients with their ongoing compliance efforts. The Office of the Inspector General’s (OIG) work plan process is dynamic and changes are made throughout the year. This allows the OIG to meet priorities and react to emerging issues. The OIG work plan website is updated monthly. While there are many topics on the work plan, the majority do not apply to coding and documentation. The information below includes an analysis of the following active inpatient topics: · Medicaid Inpatient Hospital Claims with Severe Malnutrition (OIG) · CMS Oversight of the Two-Midnight Rule for Inpatient Admissions (OIG) · Inpatient Hospital MS - DRG Coding Validation (RAC) Medicaid Inpatient Hospital Claims with Severe Malnutrition, Revised 2024 Severe Malnutrition remains an active item on the OIG workplan. Malnutrition can result from treatment of another condition, inadequate treatment or neglect, or general deterioration of a patient’s health. Hospitals are allowed to bill for treatment of malnutrition based on the severity of the condition (mild, moderate, or severe) and whether it affects patient care. Severe malnutrition is classified as a major complication or comorbidity (MCC). Adding an MCC to a claim may result in higher reimbursement as the claim is coded to a higher MS-DRG. Criteria related to severe malnutrition diagnosis and identification of severity is based on two main sets of criteria: · First, the American Society of Parenteral and Enteral Nutrition (ASPEN). o ASPEN criteria include three situations where malnutrition can occur, including: § 1) Acute illness/injury present for less than 3 months; § 2) Chronic illness present for 3 months or longer; § 3) Social and environmental circumstances limiting access or ability to self-care. o In each of these situations, ASPEN criteria has specific measurement related to energy intake, weight loss, muscle mass loss, body fat loss, edema, and reduced grip strength. · The second criteria in the Global Leadership Initiative on Malnutrition (GLIM). o The GLIM criteria include three phenotypical criteria of weight loss, low BMI, and reduced muscle mass as well as two etiological criteria of reduced food intake or absorption, and increased disease burden or inflammation. Documentation of severe malnutrition, as supported by either ASPEN and GLIM criteria, must also be supported by the treatment plan addressing the underlying etiology and continued treatment beyond the acute care setting. UASI Suggested Compliance Activities · Establish CDI and coding policies related to the use of either ASPEN or GLIM criteria in evaluating the documentation of malnutrition. · Provider education · Develop malnutrition education processes for providers with an emphasis on documentation of the appropriate malnutrition criteria. · Provide ongoing and updated education as identified in documentation audits. · Develop an audit plan · Consider a second-level review process for evaluation of malnutrition documentation, prior to release of the claim. · Establish an audit plan for concurrent and/or retrospective audits for a malnutrition diagnosis. CMS Oversight of the Two-Midnight Rule for Inpatient Admissions, Revised 2024 Prior OIG audits identified millions of dollars in overpayments for inpatient claims with short lengths of stay. Instead of billing the stays as inpatient claims, they should have been billed as outpatient claims, which usually results in a lower payment. To reduce inpatient admission errors, CMS implemented the Two-Midnight Rule in fiscal year 2014. Under the Two-Midnight Rule, CMS generally considered it inappropriate to receive payment under the inpatient prospective payment system for stays not expected to span at least two midnights. The only procedures excluded from the rule were newly initiated mechanical ventilation and any procedures appearing on the Inpatient Only List. Revisions were made to the Two-Midnight Rule after its implementation. OIG plans to audit hospital inpatient claims after the implementation of and revisions to the Two-Midnight Rule to determine whether inpatient claims with short lengths of stay were incorrectly billed as inpatient and should have been billed as outpatient or outpatient with observation. OIG also plans to review policies and procedures for enforcing the Two-Midnight Rule at the administrative level and contractor level. While OIG previously stated that it would not audit short stays after October 1, 2013, this serves as notification that the OIG will begin auditing short stay claims again, and when appropriate, recommend overpayment collections. When a Medicare beneficiary arrives at a hospital in need of medical or surgical care, the physician or other qualified practitioner must decide whether to admit the beneficiary as an inpatient or treat him or her as an outpatient. These decisions have significant implications for hospital payment as not all care provided in a hospital setting is appropriate for inpatient services. Beginning October 1, 2013, CMS adopted the Two-Midnight rule for admissions. This rule established Medicare payment policy regarding the benchmark criteria to use when determining whether inpatient admission is reasonable and necessary. In general, the original Two-Midnight rule states: · Inpatient admissions would generally be payable if the admitting practitioner expected the patient to require a hospital stay that crossed two midnights and the medical record supported that reasonable expectation. The rule was revised in 2016 to permit greater flexibility for determining when an admission that does not meet the benchmark should nonetheless be payable as an inpatient encounter. · Medicare Part A payment is generally not appropriate for hospital stays expected to last less than two midnights. · The documentation in the medical record must support that an inpatient admission is medically necessary. The most recent update to the CMS Two-Midnight Rule occurred in April 2023, when CMS finalized the rule clarifying that Medicare Advantage (MA) plans must also adhere to the Two-Midnight Rule. UASI Suggested Compliance Activities · Collaborate with utilization review (UR) or case management (CM) for potential two- midnight rule issues · If concurrent review processes are in place, review orders to ensure correct patient placement and involve UR as needed Inpatient Hospital MS-DRG Coding Validation, February 2017 This topic remains on the UASI analysis as it is still an active RAC audit topic and there are ongoing audits related to MS-DRG Coding Validation. The background associated with this ongoing audit is noted below. The OIG analyzed paid Medicare Part A claims for inpatient hospital stays from FY 2014 through FY 2019 and identified trends in hospital billing and Medicare payments for stays at the highest MS-DRG severity level. The number of stays at the highest severity level increased almost 20 percent from FY 2014 through FY 2019, ultimately accounting for nearly half of all Medicare spending on inpatient hospital stays. The number of stays billed at each of the other severity levels decreased. At the same time, the average length of stay decreased for stays at the highest severity level, while the average length of all stays remained largely the same. Specifically, nearly a third of these stays lasted a particularly short amount of time and over half of the stays billed at the highest severity level had only one diagnosis qualifying them for payment at that level. Shorter stays are not inherently problematic, but the number of these stays raises questions about the accuracy and appropriateness of the complications billed by the hospital. Although the complications billed suggest sicker beneficiaries, the shorter lengths of stay point to beneficiaries who are less sick. Excluded from this analysis are certain stays that could be expected to be shorter, such as stays during which the beneficiary died. Furthermore, over half of the stays billed at the highest severity level in FY 2019 (54%) reached that level because of just one diagnosis. In total, nearly 2 million stays had just 1 diagnosis (i.e., 1 major complication/comorbidity) that qualified the stay for the highest severity level. The rest of the submitted diagnoses for these stays were either minor complications or not complications. As a result of this analysis, CMS continues to conduct targeted reviews of MS-DRGs and hospital stays that are vulnerable to up-coding (i.e., those that are billed at the highest severity level) and the hospitals that frequently bill for them. Specifically, CMS targets stays at the highest severity level with certain characteristics, such as those that are particularly short lengths of stay or that have only one major complication. CMS also focuses on MS-DRGs that have a high proportion of stays with these characteristics and on the hospitals that frequently bill them. CMS’s RACs currently conduct coding validation reviews that incorporate some of these targeting strategies. [7] In evaluating current audit plans, consider focusing on short stays, especially those with a single CC or MCC or a complex principal diagnosis (e.g., Sepsis, AKI, ARF). UASI also suggests targeting some of the following MS-DRGs for audit depending on your case mix and volume: · MS-DRGs 064 – 066 Intracranial Hemorrhage or Cerebral Infarction · MS-DRGs 193 – 195 Simple Pneumonia and Pleurisy · MS-DRGs 280 – 282 Acute MI Discharged Alive · MS-DRGs 291 – 293 Heart Failure and Shock · MS-DRGs 308 – 310 Cardiac Arrhythmias and Conduction Disorders · MS-DRGs 377 – 379 Gastrointestinal Hemorrhage · MS-DRGs 637 – 639 Diabetes · MS-DRGs 689 – 690 Kidney & Urinary Tract Infections · MS-DRGs 870 – 872 Septicemia or Severe Sepsis · MS-DRGs 981 – 983 Extensive OR Procedures Unrelated to Principal Diagnosis UASI Suggested Compliance Activities · Select targeted MS-DRGs · Evaluate the data for the top 20-25 MS-DRGs and review for any of the above indicators plus any additional MS-DRGs with high volume. · Review the most recent PEPPER reports for MS-DRGs that may be at risk of improper payment. [8] · Establish a prioritized list of MS-DRGs for review. If possible, review cases with short lengths of stay and one MCC/CC. · Develop an audit plan · Establish an audit plan for concurrent and/or retrospective audits. · Retrospective audits can be conducted in part or wholly by incorporating selected MS-DRGs into your audit plan. Problem MS-DRGs can then be incorporated into a concurrent review work queue, if warranted. · Concurrent coding audits should be limited in scope to address specific areas impacting quality reporting and reimbursement. Timeliness is critical as these accounts are held for additional review prior to releasing the bill. Turnaround time to release cases should be short, 24 to 48 hours, to minimize the impact to DNFB (discharged not final billed) daily/weekly goals. · Audits can be conducted either internally or externally. Internal audits should be conducted based on the availability of staff with appropriate technical expertise (in coding and clinical documentation) and proficiency in communicating feedback through written reports and educational sessions. · Determine the audit scope, considering opportunities for cross-departmental collaboration to address multiple risk factors. For example, clinical documentation improvement (CDI) staff may collaborate with coding staff to conduct an audit on sepsis DRGs, addressing both coding and clinical documentation compliance perspectives. · At a minimum inpatient audit should measure and validate the following: · Accurate identification of principal and secondary diagnosis and procedure codes in accordance with official and facility-specific coding guidelines · Accurate MS-DRG or APR-DRG assignment · Accurate POA indicator assigned for all non-exempt diagnosis codes · Accurate Discharge Disposition assignment · Develop corrective action plans, including physician and coder education, based on audit findings. End Notes: 1. OIG Work Plan: https://oig.hhs.gov/reports-and-publications/workplan/index.asp 2. CMS, Approved RAC Topics, last revised 12/01/2024, accessed on January 14, 2025. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics 3. CMS Reminds Hospitals to Use Severe Malnutrition Codes Correctly. October 17, 2023. Article Detail - JF Part A - Noridian 4. Fact Sheet: Two-Midnight Rule; Oct 30, 2015. Fact Sheet: Two-Midnight Rule | CMS

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?