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or hypochlorite solution dressings, topical antibiotics, or specialized gels Background The term "pressure ulcer" is outdated.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

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.

Critical Illness Myopathy (CIM): Describes a rapidly evolving primary myopathy with generalized muscle wasting due to prolonged immobilization. Characterized by more proximal than distal weakness, sensory preservation, and atrophy depending on the duration of illness. Usually occurs in the intensive care setting. Providers may also refer to this as acquired care weakness when no specific etiology is identified. Critical Illness Polyneuropathy (CIP): Exhibits both sensory and motor manifestations, determined by physical exam and electrodiagnostic study. Characterized by more distal than proximal weakness, sensory changes, and limited atrophy. Critical Illness Polyneuromyopathy (CIPNM): Describes a combined myopathy with characteristics of both CIM and CIP. Characterized by a combination of proximal greater than distal weakness, distal sensory loss, and variable atrophy. Clinically, CIM and CIP manifest as limb and respiratory muscle weakness. Risk Factors for CIM Prolonged intubation/failure to wean Gram-negative bacteremia, hyperglycemia, hyperpyrexia, hyperosmolarity, hypoalbuminemia, hypoxia, hypotension, hyper/hypocalcemia Advanced age or female sex Sepsis, ARDS, COVID-19, asthma, organ transplant patients Use of steroids and/or non-depolarizing neuromuscular blockades (atracurium besylate, vecuronium bromide, pancuronium bromide) Diagnostic Criteria Electrodiagnostic studies: Nerve conduction studies, electromyography, and direct muscle stimulation Past medical history evaluation Clinical exam Medical Research Council (MRC) sum score: Used as an initial diagnostic measure of muscle strength in conscious patients (CIP and CIM are thought to be present if the score is less than 48) Diagnostic labs to rule out other conditions contributing to weakness Muscle biopsy: Usually necessary to firmly establish the diagnosis of CIM Provider documentation should clearly differentiate between critical illness myopathy and critical illness polyneuropathy to capture accurate code assignment. Example Scenario: A patient admitted to the ICU for sepsis with ARDS secondary to COVID-19 pneumonia has a prolonged recovery due to difficulty weaning off the ventilator. The provider documents critical illness neuropathy. Assign the principal diagnosis code for sepsis with secondary diagnosis codes for ARDS, COVID-19 pneumonia, and critical illness polyneuropathy (G62.81). A query could be considered for critical illness myopathy (G72.81) to add an additional CC if sufficient clinical indicators are present. Each code impacts risk adjustment methodologies differently. Additional Tips Critical illness myopathy is underrecognized because it has a clinical appearance that is similar to critical illness polyneuropathy. There are no identified treatment protocols other than preventative and supportive measures, with a primary focus on rehabilitation and mobilization of the patient. CIM/CIP affects over a third of severely critically ill patients and more than a quarter of those requiring ventilatory assist for at least seven days. Almost 100% of patients who demonstrate multiple organ failure experience CIM/CIP. Record reviews should consider the presence of immobility-related complications such as DVT, pressure injuries, and aspiration pneumonia. CIM and CIP can also be seen in other hospital settings and can manifest in patients with a severe illness that complicates care.  References: American Hospital Association. (2024). Coding Handbook, Disease of the Nervous System and Sense Organs; Critical Illness Myopathy. Gutmann, L., & Gutmann, L. (1999, May). Critical Illness Neuropathy and Myopathy. JAMA Neurology. Retrieved from: Critical Illness Neuropathy and Myopathy | Critical Care Medicine | JAMA Neurology | JAMA Network Prescott, L. & Manz, J. (2023). 2024 ACDIS Pocket Guide. The Essential CDI Resource (pp. 123-127). HCPro. Shepherd, S., Batra, A., & Lerner, D. (2023, August). Review of Critical Illness Myopathy and Neuropathy. NIH. National Library of Medicine. National Center for Biotechnology Information. Retrieved from: Review of Critical Illness Myopathy and Neuropathy - PMC (nih.gov)

“Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence” On December 4, 2024 , Title 42 of the Medicare Advantage plan was amended by CMS and the goal was to implement reforms that will ultimately improve healthcare access, quality, and equity for Medicare beneficiaries . This change is related to executive order 14110 by the Biden-Harris Administration, “Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence” which ensures that the development of AI does not jeopardize the advancement of equity and civil rights especially in health organizations. Institutions that do not comply with this amendment will be subjected to possible prosecution. Artificial Intelligence (AI) is rapidly becoming a prominent force in our society, and its application in healthcare is viewed with both hope and caution . Health information professionals must understand what AI entails, its capabilities, and how to employ it responsibly and ethically. With increased use of AI in healthcare, questions arise about maintaining patient trust and safeguarding data integrity , especially given the discrepancies and accuracy rate of AI-driven data collection and analysis. Additionally, with the increasing automation of revenue cycle operations in healthcare systems, ensuring coding accuracy, billing, and documentation in this evolving landscape becomes even more crucial . AHIMA and GDHP Partner for First Health Information Summit In November AHIMA and IFHIMA joined forces and conducted the first global policy summit of health information professionals and presented on public issues related to the health information profession in collaboration with GDHP (Global Digital Health Partnership), a collection of national digital health authorities and the World Health Organization (WHO). In short, digital health is the “systematic application of information and communications technologies, computer science, and data to support informed decision-making by individuals, the health workforce, and health institutions, for strengthened resilience and improved health and wellness for all.” Digital health includes digital technology-based data fields e.g., data analytics, artificial intelligence, eHealth, and telemedicine, to name a few. A central concern of the summit was the evolving impact of digital health technologies, in particular the implementation of AI, and the priorities and needs of professionals within the health information sector as they relate to digital health. During the summit, key policies were discussed that are currently impacting the health information profession. UASAID Recommended Practices  In addition to the global policy health summit, the United States Agency for International Development (USAID) recently released a position paper titled Digital Health which outlined four priorities for programmatic digital health investments . These focal areas underscore the federal government’s strategic emphasis on advancing digital health technologies . These priorities range from strengthening a country’s digital health environment to aligning digital health investments with national architecture. Additional recommended practices outlined by USAID include: · Requiring standards to enable integrated health care service delivery at scale . · Establishing standards that equate to better coordination of care , and deepening engagement with local partners . · Engaging with local partners including the private sector to support the ability of global health funders like USAID to be effective long-term partners to government ministries of health. Preparing for AI Advancement in the Mid Revenue Cycle CFO’s and Directors of HIM need to ensure compliance with CMS regulations while preparing for stricter federal-level oversight in addition to monitoring the overall performance of AI solutions. The need for education and training will continue to grow to accurately assess AI-driven data, ensuring that decision-making remains informed and aligned with regulatory standards. UASI collaborates with healthcare systems to enhance workforce capabilities in exchanging and using relevant healthcare data by reviewing and identify coding and documentation errors that impact revenue integrity and patient care , ensuring the accuracy and integrity of patient information. UASI is committed to supporting the digital transformation of health systems with long-term vision of achieving data interoperability , ensuring equity in the use of AI , and creating globally sustainable health systems .

Value-based care (VBC) models are continuing to gain traction to improve care outcomes while controlling costs. However, the transition to VBC comes with its own set of challenges, specifically around risk adjustment, which is vital to ensuring accurate reimbursement. To better understand these hurdles, UASI asked industry leaders for their insights into the complexities of implementing and managing Risk Adjustment in VBC models. Key Challenges in Adopting VBC Models Industry leaders in healthcare highlighted several challenges related to adopting Value-Based Care models and identified several barriers; Staff resistance to new care delivery and reimbursement models, and a lack of education and training hinders understanding and adoption of VBC. Aligning processes and workflows with new care models can disrupt established practices, while difficulties in aligning with payor contracts, due to varying quality metrics and reimbursement formulas, create further obstacles. Additionally, many healthcare systems face inadequate operational capacity and a shortage of a specialized workforce , making it difficult to scale VBC models effectively. Resources for VBC Implementation and Optimization To effectively manage value-based care (VBC) models , industry leaders weighed in and identified several key resources to better support VBC implementation. Those organizations with more mature programs have 6 key components in place in managing a successful program: The main needs identified were data analytics to track patient outcomes and costs Comprehensive training and education programs to equip staff with the knowledge to effectively implement VBC. Leaders in Risk Adjustment would like to see a defined strategy and objectives within their organizations to guide decision-making The tools and technology to support the strategy. Financial incentives from payors are needed such as quality measures and shared savings programs to leverage more support for VBC implementation. Regulatory guidance can also help health systems to navigate VBC complexities and ensure compliance. Challenges in Data Accuracy and Metrics for Evaluating Success Data accessibility and accuracy are major barriers within Risk Adjustment. Ensuring that data is comprehensive and accurate is needed for calculating risk scores and understanding where to focus efforts. With multiple risk adjustment models in place, organizations struggle to find processes that create efficiencies. Additionally, provider burnout and workflow management issues arise as providers navigate various VBC models. To ensure effectiveness, there are a set of metrics to evaluate Risk adjustment and value-based care models: Hospital Readmission Rates : Reducing hospital readmissions indicates the success of preventive care and is a goal of VBC. · Mortality Rates : Mortality rates focus on the overall quality of care and patient outcomes. Cost per Patient per Month (PMPM) and Total Cost of Care : Tracking the cost per patient is essential to managing the financial aspects of VBC, ensuring that the system remains financially viable while improving care quality. Total cost of care is a broad metric that captures the financial efficiency of the care model. Shared Savings Revenue : This metric tracks the financial savings generated through VBC initiatives, which are shared between providers and payors. Quality Scores (HEDIS, STAR Ratings) : National quality measures such as HEDIS and STAR ratings provide objective benchmarks for evaluating the effectiveness of care delivery. Risk Adjustment Accuracy Scores (RAF, Recapture Rate) : These scores are essential for evaluating the precision of risk adjustment models. RAF is the estimated yearly cost to treat a patient whereas the Recapture Rate refers to how well a provider captures recurring HCC diagnoses and is also used to understand future healthcare costs. Suggestions for Improvement Improvements must be organizational and system wide as industry leaders highlight that viewing Risk Adjustment and VBC as just a revenue cycle or coding issues is a major barrier. Instead, these challenges require an integrated approach involving clinicians, administrators, and payors to drive the necessary changes . As previously stated, healthcare organizations face challenges like staff resistance, workflow management, and data accessibility/accuracy. However, with the right resources these obstacles can be overcome. Let UASI help you bridge the gap by assessing your Risk Adjustment practices, identify gaps, and develop targeted solutions.

In 2021, the New Technology Add-on Payment (NTAP) program was created by The Center for Medicare & Medicaid Services (CMS) to increase the use of new inpatient technologies in the Medicare population. CMS uses NTAP codes for qualifying products that promise improvement in process or outcomes. Additionally, these new medical services and technologies are eligible for an add-on payment known as NTAP which presents significant reimbursement opportunity for hospitals and healthcare systems that adopt these technologies. Eligibility Criteria for NTAP Payments To be eligible for the NTAP, these technologies must meet the following 3 criteria. When the following criteria are met, the NTAP payments are significantly greater than the standard Medicare Severity Diagnosis-Related Group (MS-DRG). 1.) Technology must be new within 2-3 years of market introduction. 2.) The technology must “substantially improve the diagnosis or treatment relative to currently available technologies and are inadequately paid otherwise under the current diagnosis-related group (DRG) reimbursement rates.”1 3.) The technology is deemed inadequately compensated under the current MS-DRG, as its average standardized charge for inpatient cases exceeds the set cost threshold. FY 2025 Program Expansion: 39 New Technologies Approved The number of approved technologies has increased each year since its inception. The FY 2025-year list is the most extensive since the program began and includes 39 Total NTAPs. • CMS finalized the continuation of new technology add-on payments for 24 existing new technologies • CMS finalized discontinuing new technology add-on payments for 7 current new technologies • CMS finalized 16 of the original 27 new technologies submitted for new technology add-on payments under the traditional and alternative pathways Financial Impact: What NTAP Can Mean for Your Hospital’s Reimbursement According to CMS, new technology add-on payments are limited to the lesser of 65% of the costs of the technology, or 65% of the amount by which the costs of the case exceed the standard MS–DRG payment”. The most substantial financial impact approved for FY 2025 Casegevy and Lyfgenia. Both are medications for gene therapies that treat sickle cell disease. These medications qualify for 75% NTAP amount resulting in a maximum payment of $1.65 Million for Casgevy and $2.32 Million for Lyfgenia. Key Steps to Maximize NTAP Reimbursement For hospitals and health systems, it is essential to take the following steps to ensure full NTAP reimbursement: Accurate Coding: Make sure the correct ICD-10-PCS code(s) are included on claims to qualify for NTAP payments. Missing or inaccurate codes can lead to lost revenue. Annual Review of NTAP Services: Each year, inpatient coding staff should review the latest list of approved NTAP services and technologies to stay updated on new opportunities for reimbursement. Routine Audits: Conduct regular internal and external audits to confirm that all eligible procedures and technologies are correctly coded and reimbursed. These audits help identify and prevent potential revenue leakage. Taking these proactive measures can help ensure your hospital captures all eligible NTAP reimbursements. Not Sure if You’re Capturing All Possible NTAP Revenue? Contact UASI for a comprehensive NTAP assessment. Our expert audit team is ready to help your hospital secure eligible NTAP payments and maximize revenue potential. Do not let money slip through the cracks - Reach Out Today! References 1. Adoption and Trends in the Medicare New Technology Add-On Payment Program - PubMed Central (PMC) 2. New Medical Services and New Technologies - Centers for Medicare & Medicaid Services (CMS)

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.

For FY 2025 CPT has deleted the following audio only codes. 99441 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment: 5-10 minutes of medical discussion 99442 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment: 11-20 minutes of medical discussion 99443 Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment: 21-30 minutes of medical discussion CPT has created 16 new telehealth codes (98000-98016). But at this time per the Federal Register to be published on 12/9/2024 Medicare does not plan to recognize these codes. CMS plans to assign payment status code “I” ) Not valid for Medicare purposes) to these codes. 1  Therefore, for evaluation and management (E/M) visits performed over telehealth, you’ll continue to use the existing E/M codes, such as 99202- 99215 for Medicare payers. It’s unclear which private payers – if any- do plan to recognize 98000-98016 in 2025. **Most insurers will be issuing their 2025 coverage guidelines in coming weeks. 2 1. Federal Register :: Public Inspection: Medicare and Medicaid Programs: Calendar Year 2025 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Prescription Drug Inflation Rebate Program; Medicare Overpayments 2. 2025 Medicare Fee Schedule Targets Telehealth, Advanced Primary Care Management

Diabetes Mellitus: is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia.  The 2 main categories of diabetes mellitus are: Type 1 - The body’s immune system destroys the beta cells within the pancreas, leading to an inability to produce insulin. Type 1 diabetes requires daily insulin therapy. Historically described as juvenile-onset diabetes. Accounts for less than 10% of all cases of diabetes mellitus. Type 2 - The body still produces insulin, but the body’s cells are unable to utilize the insulin efficiently, leading to insulin resistance. Liver and fat cells are inefficient at absorbing the insulin, resulting in higher glucose levels and increased insulin production. The pancreas loses the ability to produce adequate levels of insulin. May require insulin replacement. Hyperglycemia : Blood sugar > 140 mg/dL Provider documentation should clearly identify diabetes complications as “hypoglycemia” or “hyperglycemia” instead of “uncontrolled diabetes” to ensure accurate code assignment. Example: A patient with a history of type 2 diabetes was found to have blood sugars ranging from 150-220 mg/dL. The provider documents “uncontrolled diabetes” in the H&P. A query should be sent to clarify the diagnosis as “Diabetes mellitus type 2 with hyperglycemia” for accurate capture of the diagnosis. Diabetes mellitus type 2 with hyperglycemia is an Elixhauser variable and an HCC. Provider documentation should clearly differentiate POA status of DM with hyperglycemia when related complications are also documented, such as HHS or DKA. Example: When a provider documents hyperglycemia as POA and a second provider later determines the patient has DKA or HHS. CDI should send a query for clarification of the POA status of documented conditions. CDI would also send a clinical validation query if HHS or DKA is lacking sufficient clinical evidence to support the diagnosis. Provider documentation should clarify if “diabetes type 2 with hyperglycemia” is a complication of a medical treatment to capture appropriate code assignment. Example: A patient with pre-existing type 2 diabetes mellitus presented with hyperglycemia, and the provider notes hyperglycemia is likely secondary to autoimmune DM, which occurred following immunotherapy initiation. Assign codes for Diabetes type 2 with hyperglycemia, and an additional code for the adverse effect of antineoplastic and immunosuppressive drugs. If there is any question of a cause-and-effect relationship, a query would be warranted for clarification. In the OP arena, look for an A1c > 7 to consider a query for control status, unless the provider documents a specific goal in the visit note i.e. A1c goal is < 7.5, etc. NCQA / HEDIS Comprehensive Diabetes Care measure looks for HbA1c control (<8.0%). See below: