Education and Tips
Learn useful information and tips used in the industry.
Topic Outpatient CDI: Pacemaker Status, Sacroiliitis Office Visit: 76-year-old female, lives alone. Follow up re: Cardiology, Orthopedic (low back pain) follow up, refills needed. PMH: Hypothyroidism, CAD, Osteoarthritis, Lung Cancer, Pacemaker status, lawn mower accident as teenager- amputation of fourth, fifth toe on left foot. Home medications: Oscal, Synthroid, Losartan Vitals: BP 115/64, HR 98,… Read More »Monthly CDI Scenario Discussion – October 2023
Read MoreComparing Codes Across ICD Versions: Pneumonia, present on admission By: Mary H. Stanfill, MBI, ACHIP, RHIA, CCS, CCS-P, FAHIMA As the US has started exploring ICD-11 adoption, UASI is dedicated to looking for ways to make it’s adoption less intimidating. The WHO ICD-11 classification is very different from the 10th version that the United States… Read More »ICD-11 Monthly – September 2023
Read MoreOutpatient Documentation & Coding Issues, September 2023 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 July 2023. The focus is on outpatient initiatives related… Read More »UASI Compliance Analysis
Read MoreThe Centers for Medicare & Medicaid (CMS) announced in the fiscal year 2022 Hospital Prospective Payment System final rule published on August 2,2021 that it was adopting an April 1 implementation date for ICD-10-CM and ICD-10-PCS code updates, in addition to the annual October 1 update, beginning with April 1, 2022. The April 1 implementation… Read More »Coding Tips: Maintenance of the ICD-10-CM & ICD-10-PCS Coding Systems
Read MoreTopic: Clinical Validation of Acute Kidney InjuryH&P: 79 y/o F presents with cloudy urine and labored breathing. Patient has suprapubic catheter draining to bedside bag which was last changed 10 days prior per daughter. Patient started on IV ceftriaxone, IV furosemide, and 1 liter NS bolus. Suprapubic catheter was changed during hospitalization.PMH: chronic systolic CHF,… Read More »UASI CDI Monthly Scenario Discussion – Clinical Validation of Acute Kidney Injury
Read MoreThe WHO ICD-11 classification is very different from the 10th version that the United States modified to create the ICD-10-CM code set that is used for reporting healthcare services on claims in the US today. In monthly code comparisons, we’ve looked at codes that are pre-coordinated or post-coordinated in ICD-11 and compared them with the… Read More »Comparing Codes Across ICD Versions: Spinal stenosis
Read MoreComparing Codes Across ICD Versions: Cholecystitis with cholelithiasis By: Mary H. Stanfill, MBI, ACHIP, RHIA, CCS, CCS-P, FAHIMA The WHO ICD-11 classification is very different from the 10th version that the United States modified to create the ICD-10-CM code set that is used for reporting healthcare services on claims in the US today. One distinct… Read More »ICD-11 Monthly – August 2023
Read MoreH&P: 38 y/o male presents with nausea, vomiting, dizziness, dark urine, and thigh pain after participating in a marathon. PMH: ADHD Home medications: Adderall XR 20mg once daily Vitals: HR 125, RR 23, BP 90/42 PE: lethargic, dry mucous membranes, poor skin turgor, thigh muscle pain Labs: Admission labs -calcium 7.0 mg/dl , Potassium 4.4,… Read More »UASI Monthly CDI Scenario Discussion – Rhabdomyolysis
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