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For over 40 years, UASI has bridged the gap between people and processes in financial, clinical and operations by providing solutions that reduce revenue leakage, enhance operational efficiency, and ensure quality and compliance.
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At UASI, we optimize your risk adjustment and value-based care initiatives with our specialized risk-based services, ensuring accurate coding and improved financial outcomes.
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“I have worked with UASI for many years, they are my go to for CDI. UASI provides experienced CDI staffing resources as well great products with their CDI assessment and their customizable CDI audits. Partnering with UASI is helping our CDI team continuously grow and improve.”
- Tallahassee Memorial Healthcare
Education
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Common definitions for this discussion: Adverse Effect: occurs when a substance is taken according to direction and a reaction occurs Poisoning: indicates improper use of medication including combination with alcohol, overdose, wrong drug, wrong dose, or taken in error Underdosing refers to taking less or discontinuing a medication that is prescribed Toxic Effects: a reaction, consequence, or effect of a non-medicinal substance such as alcohol, animal venom, or carbon monoxide Provider documentation needs to be clear whether a drug was taken as directed or improperly administered to determine an adverse effect vs. poisoning. For example, a patient with a GI bleed due to Coumadin therapy would need clarification if the Coumadin was taken properly or not taken properly. Taken properly as directed would have an adverse effect – Principal diagnosis is the nature of the adverse effect. GI bleed is associated with Coumadin therapy, taken properly. Taken improperly would be poisoning – The principal diagnosis is the poisoning effect from improper coumadin. GI bleeding is associated with Coumadin therapy, not taken properly Provider documentation should be clear whether a diagnosis results from a cause/effect of poisoning. For example, a patient admitted/discharged with a diagnosis of musculoskeletal chest pain with cocaine use just before the onset of symptoms. Chest pain associated with cocaine use provides clarity on the etiology of the pain. Poisoning is the principal diagnosis, and chest pain is the secondary diagnosis. Provider documentation must be clear whether a diagnosis results from a toxic effect. For example, a patient is admitted with right hand cellulitis and documentation in the nurse’s notes reflects patient was bitten by a spider on the right hand the day before admission. Right-hand cellulitis due to spider bite provides clarity of the cause of the cellulitis. A toxic effect diagnosis would be the principal diagnosis and cellulitis would be a secondary diagnosis. Codes for underdosing should never be assigned as principal diagnosis or first listed codes. The exacerbation or relapse of a medical condition due to under dosing is the principal diagnosis. For example, seizure disorder will be principal when a patient is admitted after having a seizure and noted with subtherapeutic Dilantin levels. Additional Tips: Use as many codes as necessary to describe completely all manifestation of the adverse effect, poisoning, underdosing, or toxic effect. If two or more drugs, medicinal or biological substances are taken, code each individually The poisoning codes have an associated intent as their 5th or 6th character (accidental, intentional self-harm, assault and undetermined). If the intent of the poisoning is unknown or unspecified, code the intent as accidental intent. The undetermined intent is only for use if the documentation in the record specifies that the intent cannot be determined. Documentation of a change in the patient’s condition is not required in order to assign an underdosing code. Documentation that the patient is taking less of a medication than is prescribed or discontinued the prescribed medication is sufficient for code assignment. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded too. If marijuana is legalized for therapeutic/recreational use per state legislature (depending on the documentation in the chart), it is no longer considered an illicit drug. To capture an adverse reaction in this case, it would be coded as poisoning or adverse effect.
It’s not new news that work as we knew it has changed dramatically over the past few years with more employees working remotely than ever before. While this is a newer phenomenon for many HIM employees, at UASI we’ve been working this way for over 20 years. In order to recruit and retain the best in the field, and cut down on travel hassle for our teams and costs for our clients, we built our remote coding services practice 23 years ago. Our success operating this way led us to quickly adopt remote working for our Revenue Integrity, CDI, Audit and Coding Review and consulting teams as well. This has enabled us to find the best talent no matter which zip code he/she lives in over the years. Working remotely can be lonely and people can feel isolated, so it’s important to engage your staff regularly and in various ways. Though there are countless articles and blog posts about working remotely successfully, it’s still a struggle for many. Regardless of having 20+ years of experience operating this way, it never hurts to remind ourselves what works, so we wanted to share a few tips. Routinely schedule calls with your team members to check in and see how they personally are doing and how the work is going. Make sure to personalize the call and ask if goals are being met and if there are issues preventing their success or milestones to celebrate. Send emails consistently that not only check in on people, but also share something fun and/or educational such as: Industry hot topics and/or education Fun facts for that month or week Celebrations such as birthdays, births, graduations, work anniversaries Congratulations on obtaining new credentials or a personal milestone Make Department meetings fun and educational. After providing an overview of the team performance and updates, ask a few people to share something about themselves and/or have a few team members take turns presenting an educational topic briefly. This enables them to work together on something, work on something different than their day-to-day responsibilities and educate the team at the same time. You can even play online games to get to know each other or just to have fun. Our teams play trivia games, bingo, and even industry-related word searches. It is a simple way to engage people and creates opportunities to bond with one another. Share good news with the team when someone is successful or gets a compliment from a client. This way the whole team can share in the success and appreciate the fact that they are working with smart, successful teammates. You can even set up a system to allow staff to nominate each other for great work or achievements for anyone in the company. At UASI, we have our Values-In-Action program where our associates nominate one another for demonstrating our values. It brings energy to our day when those nominations get recognized and reinforces the values of the organization at the same time. It’s not only a proud moment for a person when he/she is recognized, but those nominating get satisfaction from it as well. Conduct remote social activities. Some successes we’ve had are creating a social media “breakroom” for staff only, creating holiday cookbooks or even gift exchanges where you can celebrate together virtually. Remote gift exchanges do take a little coordination, but how fun is it to get a “surprise” in the mail? Invite individuals to participate in health-related challenges, such as step challenges, mindfulness meditation or some type of self-care. These are important because let’s face it, we sit all day. If we can help our teams stay active, they will be healthier and happier. At UASI we frequently have these types of challenges frequently with incentives to participate. In addition, one of our senior leaders conducts a weekly mindfulness mediation session. It’s a great way to break up the day and feel energized for the rest of the week. Always, always encourage staff to share ideas, issues and solutions. Your employees have the bird’s eye view of their jobs and many have great insight and suggestions on ways to improve processes or tools. At UASI we do this regularly in our team meetings, but we also have a corporate Innovation Program where anyone can submit ideas for improvement. These ideas are evaluated by a small committee on a regular basis and then the person submitting gets feedback on the idea. If we decide to pursue the idea, many times the submitter participates in crafting the solution. If we decide to not take action at the moment, the submitter is given the rationale. In this way, everyone knows their ideas are valued whether or not we decide to implement them. Your people are what make your company great. Working remotely can be lonely and people can feel isolated so it is important to ensure you have a good engagement program in place. Keep it up or get one or more of these started. Today. Don’t delay.
Respiratory failure: a syndrome in which the respiratory system fails in one or both of the functions of gas exchange, which are oxygenation and carbon dioxide elimination. It can be classified as hypoxemic (type 1), hypercapnic (type 2), or a combination of both. Respiratory failure can be acute or chronic. The etiology of acute respiratory failure is often determined to be pneumonia, bronchiolitis, croup, trauma, or exacerbation of a chronic condition such as asthma. Chronic respiratory failure: a condition in which the inability to effectively exchange carbon dioxide and oxygen results in chronically low oxygen levels or chronically high carbon dioxide levels. Usually the underlying etiology is chronic lung disease such as cystic fibrosis, neuromuscular disorders, or muscular dystrophy. Diagnosis requires the use of home oxygen or ventilator support, or having baseline SaO2 < 88% on room air or pCO2 > 50 with normal pH. Acute respiratory distress syndrome (ARDS): often considered the end stage of acute respiratory failure, occurring when fluid builds up in the alveoli which prevents the lungs from filling with enough air. This leads to less oxygen reaching the bloodstream and organs, reducing organ function. ARDS patients have a moderate to severe impairment of oxygenation as defined by the ratio of partial pressure arterial oxygen and fraction of inspired oxygen (PaO2/FiO2). Chest imaging exhibits bilateral opacities/pulmonary edema not explained by cardiac failure or fluid overload. Diagnostic Criteria for Acute Respiratory Failure in Pediatric Patients Pediatric patients often present differently than adults and can also decompensate more quickly. Children may present with the following: Lethargy or irritability Appear anxious or demonstrate inability to concentrate May prefer positioning to aid in breathing (i.e sitting up, leaning chest/head forward) Mouth breathing, drooling Interrupted feeding and diet patterns Generally, oxygen saturation <88% on room air is supportive of acute hypoxemic respiratory failure. ABGs are rarely measured when assessing children’s respiratory function. However, diagnostic ABG levels include: PaO2 of < 60 mmHg on room air Acute increase in pCO2 of 10-15 mmHg pH decreasing to 7.32 or less PaO2 / FiO2 (PF) ratio of < 200 or < 300 Intubation/mechanical ventilation is not required to support the presence of acute respiratory failure. An acute respiratory condition and any of the following treatments may support the presence of acute respiratory failure: Supplemental oxygen with FiO2 ≥ 0.30–0.35 to maintain SpO2 ≥ 90% Any level of high-flow nasal cannula Any level of nasal continuous positive airway pressure (nCPAP) or nasal bilevel positive airway pressure (BiPAP) (except for obstructive sleep apnea) Provider documentation often describes the patient’s symptoms and assessment without stating the words “acute respiratory failure.” If clinical indicators support the presence of acute respiratory failure, a query should be sent. For example, “acute respiratory distress”, “acute exacerbation”, “respiratory insufficiency”, “respiratory acidosis” are frequently used terms that may not capture the patient’s true complexity. Providers frequently use templated notes that are copied/pasted into subsequent notes. This is a great opportunity for CDI to provide education on customizing these templates. Templated notes often have statements such as “no acute distress”, and “normal appearance” which can suggest that the patient did not have respiratory failure. Additional Tips: • Chapter-specific coding guidelines (particularly with newborns) that provide sequencing direction take precedence when determining the principal diagnosis. • A code from subcategory J96.0, Acute respiratory failure, or subcategory J96.2, Acute and chronic respiratory failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital. • Although acute respiratory failure always has an underlying cause, do not default to the etiology as the principal diagnosis. The circumstances of the admission must be considered. Respiratory failure may be listed as either the principal or a secondary diagnosis. • For acute respiratory failure due to COVID-19, assign code U07.1, COVID-19, followed by code J96.0-, Acute respiratory failure. • If the documentation is not clear as to whether acute respiratory failure and other conditions are equally responsible for occasioning the admission, query the provider for clarification. • Common respiratory failure risk factors to look out for in pediatric patients include: young age, premature birth, immunodeficiency, chronic pulmonary/cardiac/neuromuscular diseases, anatomic abnormalities, cough/rhinorrhea/other URI symptoms, and lack of immunizations. • Other conditions that are not pulmonary in nature which may lead to acute respiratory failure include: status epilepticus leading to encephalopathy and decreased respiratory drive, a traumatic head injury or anoxic brain injury that stops respiratory drive, and septic shock. References: Pediatric Acute Lung Injury Consensus Conference Group. (2015). Pediatric acute respiratory distress syndrome: Consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatric Critical Care Medicine, 16(5), 428–439. https://doi.org/10.1097/PCC.0000000000000350 Springer, S. C. (2012, December 5). Pediatric respiratory failure. Medscape. https://emedicine.medscape.com/article/908172-overview Savage, L. (2017). Pediatric CDI Building Blocks for Success (pp. 64–71). HCPro.
Insights
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“Out of Sight, Out of Mind” - A Cautionary Note for Hospitals Reducing Their Value-Based Care (VBC) Patient Populations
Burnout in healthcare is a significant and growing issue, affecting everyone from frontline clinical staff to administrative personnel. Despite ongoing efforts to tackle this challenge, burnout remains alarmingly high among physicians. According to the 2024 Medscape Physician Burnout & Depression Report, 49% of physicians are experiencing burnout, a modest improvement from the previous year’s 53%. This underscores the lingering impact of COVID-19 and the heightened pressures within the healthcare system. Healthcare practices are juggling Fee-For-Service (FFS) and Value-Based Care (VBC) models simultaneously. This means that there is either one generalized process that effectively serves both models or two distinct processes, rules, tools, and approaches. The FFS model pushes providers to see more patients and perform more procedures, which can be overwhelming and lead to unnecessary services. On the other hand, VBC emphasizes quality care and chronic disease management over the long term, requiring various management methods beyond traditional encounters. Balancing these models and meeting compliance demands can be daunting and contribute to burnout. Top 5 Strategies You Can Implement Now to Reduce Burnout 1. Simplify Administrative Tasks: Reducing bureaucratic tasks like charting and paperwork by employing Clinical Documentation Integrity (CDI) and coding professionals allows providers to focus more on patient care and less on administrative duties. Organizations that utilize CDI professionals reduce denials, re-work, and improve the effectiveness of their queries. This reduces the administrative burden not only for physicians but also for CDI and coding professionals. 2. Proactive Scheduling of Patients: Prioritizing Annual Wellness Visits (AWVs) and transitional care visits using Risk Adjustment Factor (RAF) scores, or Hierarchical Condition Categories (HCCs) helps manage resources efficiently and reduces provider burnout. Using data to understand current RAF scores and recapture opportunities by patient ensures that the patients with the most impact are seen at least annually and given their chronic conditions, more frequently as appropriate. 3. Conduct Prospective CDI Reviews: Ensuring CDI professionals prospectively review records and communicate priority clinical indicators guarantees accurate medical documentation, reduces the time providers spend researching patient records in advance, and ensures optimal outcomes while reducing re-work. 4. Effective Use of Coders: Utilizing professional coders to handle diagnosis codes for claims reduces compliance issues, lost revenue due to over-coding or under-coding, and increased frustration. A streamlined coding process ensures that claims are processed expeditiously, resulting in faster cash flow. This not only saves time but also reduces compliance risks and the administrative burden on physicians. 5. Leverage Technology: Implementing advanced technology solutions, such as our proprietary software RAF Vue™️ , can significantly enhance efficiency and accuracy. Instant insights into chronic code capture and recapture opportunities allow for quick identification of patients with the greatest treatment and financial impacts. With a centralized, patient-level view and automatic calculation of reported and potential RAF scores, RAF Vue™️ generates comprehensive reporting at the patient, provider, and reviewer levels. Best of all, RAF Vue™️ can achieve immediate go-live without requiring EMR integration, reducing the technological burden on your practice. Comprehensive Support from UASI At UASI, we specialize in guiding healthcare organizations through the intricacies of risk adjustment and value-based care. We evaluate programs, assess needs, identify priorities, and create effective strategies to reduce administrative burdens, enhance care quality, and improve financial outcomes. Our goal is to support your practice in reducing burnout and improving patient care. Let us help you navigate the complexities of risk adjustment and value-based care to achieve sustainable success. Contact us today to learn how we can support your practice in reducing burnout and improving patient care.
Our HCC experts Nancy Koors, Vice President of Corporate Development and Mary Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, Vice President of Consulting Services recently teamed up with Colleen White, MSM, BSN, RN, CPC, Ambulatory CDI Program Manager at ChristianaCare, for a webinar discussing Successful HCC Risk-Adjusted Programs: Tactics to Manage Your Risk-Adjusted Population. ChristianaCare is featured on the World’s Best Hospitals 2022 list by Newsweek and among America’s 50 Best Hospitals 2022 according to Healthgrades. The webinar primarily focused on UASI’s Risk Adjustment Maturity Model and its four phases: Explore, Define, Implement, and Optimize, as well as lessons learned from ChristianaCare as they progressed through each phase. Here is a breakdown of each phase. Keep reading to find out in what phase your organization is. Explore: An organization is aware that they have a growing risk-adjusted patient population, but they may or may not know how many patient lives they are managing or their RAF scores. Whether they know their RAF Scores or not, they probably realize that their scores are not a true reflection of the health of their population. There are a lot of uncertainties in this phase such as: How accurate is our documentation? How do we analyze the sheer volume of patients and visits? Where do we start? How do we prioritize? A reactive approach to the explore phase is driven by reimbursement not reflecting the care provided. Define: The facility begins reviewing their risk adjusted patients to identify which patients do not have accurate RAF Scores. Based on this, the facility will prioritize patients for review to ensure the time spent is most productive. Typically, organizations begin to use Excel to manage the work queues. This can work early in the process, but as the patient volume increases and workflow begins to include other areas of the health system, it becomes problematic as the amount of data is difficult to manage and manual data entry becomes less reliable. The facility typically finds a chronic condition to focus on or a group of physicians to run a pilot test to determine the right people, processes, and tools needed. Implement: The hospital has moved beyond a pilot test and begins to implement a program where consistent procedures are followed across multiple clinics or provider groups. The team typically grows and the workflow becomes the norm. A cross-training program might exist for their growing team. More sophisticated tools are sought to replace Excel. Optimize: At this point the hospital has established a program with consistent policies and procedures. Performance is monitored, and they have been able to solve some of the easier issues such as recapturing previously identified HCCs year to year. The next step is to ensure they have captured the chronic conditions for their patients that have not been previously reported. Trends in chronic conditions will be analyzed and compared within their region. Data analytics and reporting become critical at this phase so that the health system can easily prioritize their work. If you are interested in finding out where you are in the process of managing your risk-adjusted population, take our 3-Minute Risk Adjustment Checkup . You can also download a white paper covering insights for managing HCCs and risk-adjusted populations on our website.
Coding Tips
Stay ahead with UASI Coding Tips section, featuring practical advice, industry updates, and best practices to enhance your coding accuracy and efficiency.
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:
Coming FY 2025 ICD-10 is expanding subcategory E10 to identify stages of Presymptomatic Diabetes Mellitus Come October 1, we will now be able to identify diabetes at earlier presymptomatic stages. ICD -10 is expanding subcategory E10 to identify stage1 and 2 presymptomatic diabetes. Type 1 diabetes can now be most accurately understood as a disease that progresses in three distinct stages. STAGE 1 is the start of type 1 diabetes. Individuals test positive for two or more diabetes-related autoantibodies. The immune system has already begun attacking the insulin-producing beta cells, although there are no symptoms and blood sugar remains normal. 1 STAGE 2 , like stage 1, includes individuals who have two or more diabetes-related autoantibodies, but now, blood sugar levels have become abnormal due to increasing loss of beta cells. There are still no symptoms. 2 STAGE 3 is when clinical diagnosis typically takes place. By this time, there is significant beta cell loss and individuals generally show common symptoms of type 1 diabetes, which include frequent urination, excessive thirst, weight loss, and fatigue. 3 1,2,3 Type 1 diabetes staging classification opens door for intervention | TRIALNET Type 1 Diabetes TrialNet
When a patient has a hysterectomy in which structures are detached laparoscopically, and a separate incision is made or a portal is extended, for specimen removal, the procedure is reported as a laparoscopic procedure, since CPT has established that extending a portal or making a separate incision for specimen removal does not equate to an open procedure. *This updated coding guidance supersedes the advice in Coding Clinic for HCPCS Fourth Quarter 2019. *Coding Clinic for HCPCS, Second Quarter 2024
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