Bridging Financial, Clinical & Operational Processes for Optimal Outcomes
Coding • CDI • Denial Management • Risk Adjustment • PSI
Program Design, Implementation & Optimization • Assessments & Audits • Staffing & Managed Services • Education & Training
Expertise in Enhancing Revenue, Efficiency, Operations and Compliance for Healthcare Systems
40+ Years
Proven track record in revenue cycle management
1100 +
Hospital Facilities and Physician Groups Nationwide
540
Credentialed Consultants & Staff
96% +
Coding accuracy based on 3rd party audits
Top 3 Best in KLAS for outsourced coding for past 8 years
UASI is Trusted by 1100+ Hospital Facilities and Physician Groups Nationwide
Our Solutions
Mid-Rev Cycle Solutions that Work
Program Design, Implementation and Optimization
Our pragmatic approach targets specific opportunities to enhance standards, fiscal objectives, and regulatory compliance, thereby boosting performance and fortifying outcomes.
Assessments and
Audits
Achieve higher quality outcomes and an attainable ROI with ongoing and strategic audits and reviews of your operation.
Education and Training
We facilitate the shift to value-based care with expert support in people, processes, and technology, offering a measured approach for quick ROI and scalable success.
Staffing and Managed Services
Achieve coding, CDI, or revenue integrity staffing flexibility with confidence, surpassing accuracy, quality, and productivity goals through our tiered support model.
Health in Context: Understanding the Impact of Social Determinants of Health (SDoH)
Summary of a Presentation by Rachel Mack, MSN, RN, CCDS, CDIP, CCS, CRC at the 2025 CHIMA Annual Meeting
In this must-read article, you will:
Uncover how Social Determinants of Health (SDoH) like housing, food access, and education drive health outcomes beyond clinical care.
Reveal the real-world effects of SDoH on chronic illness, health disparities, and population-level risks.
Demystify the power of ICD-10-CM Z codes in capturing and addressing social needs in medical records.
Break down the nine Z code categories that illuminate a patient’s lived experience and care barriers.
Tackle the documentation challenges and discover innovative solutions that support equitable, data-informed care.
Download the FULL ARTICLE
for INSTANT ACCESS
“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
Our Services
Discover a comprehensive range of healthcare solutions designed to optimize revenue, enhance compliance, and improve operational efficiency. From coding and CDI to risk-based services and revenue integrity, UASI provides expert support to meet your unique needs.
Explore our INSIGHTS section for valuable resources, including articles, results, whitepapers, case studies, and more. Stay informed and gain expert knowledge to drive your healthcare organization's success with UASI.
Hospitals can no longer focus exclusively on assigning the correct MS-DRG as value-based care (VBC) demands a more comprehensive approach that centers on complete, specific, and accurate documentation and coding. Reimbursement, quality rankings, and publicly reported outcomes now rely on data integrity at the patient level. The Shift to Value-Based Care Value-based care prioritizes quality over quantity. Payment models reward outcomes, care coordination, and patient experience rather than volume of services, and this transformation is reshaping inpatient payment strategies. According to CMS, over 90% of Medicare Advantage enrollees are now in plans that include some form of value-based payment model (CMS, 2023). Programs such as the Hospital Value-Based Purchasing (VBP) program adjust hospital reimbursement based on performance in key domains: mortality, safety, patient experience, and efficiency. Under the VBP program, CMS withholds 2% of base DRG payments and redistributes those funds based on performance scores (CMS VBP, 2024). Hospitals that perform well receive a net increase in payments and those that underperform lose a portion of their DRG reimbursement. These performance scores also feed into the CMS Star Ratings, impacting public perception, competitive standing, and contract negotiations with commercial payers. The Role of Accurate Coding Coding accuracy is foundational to success in value-based models. Accurate codes support appropriate reimbursement, enable risk adjustment, and fuel quality improvement efforts. They also ensure complete and defensible clinical documentation. Inaccurate or incomplete coding can exclude key diagnoses from risk models, skewing expected outcomes and exposing hospitals to financial penalties or public underperformance. Understanding Risk Adjustment Risk adjustment allows payers to compare patient outcomes across hospitals fairly by accounting for differences in patient acuity and comorbidities. CMS uses tools such as the Elixhauser Comorbidity Index to assess 30-day mortality, readmissions, and safety events. Diagnoses must be coded correctly and tagged as Present on Admission (POA) to be included. The mortality domain under the CMS Stars program includes seven metrics and evaluates all-cause mortality within 30 days. According to CMS, more than 3,000 hospitals receive mortality scores based on risk-adjusted data derived from claims and coded diagnoses (CMS Hospital Compare, 2024). Risk adjustment also influences private payers and rankings. U.S. News & World Report hospital rankings and Leapfrog scores incorporate risk-adjusted data derived from coded information. Missing a chronic condition like COPD, CKD, or diabetes may not impact the DRG but could dramatically alter performance scores and ranking outcomes. CDI, Coding, and Strategic Impact Clinical Documentation Integrity teams must prioritize specificity and relevance to risk models. This includes expanding review focus to non-mortality domains such as readmissions and complications. Coders and CDS specialists should be equipped to query not only for DRG optimization but also for clinical accuracy and data completeness. Hospitals that invest in this strategy see results. According to the AHIMA Foundation, hospitals with strong CDI programs report an average increase in captured comorbid conditions of 25–30%, resulting in improved risk scores, quality metrics, and reimbursement (AHIMA CDI Impact Study, 2023). Real World Example Consider the following inpatient scenario: A patient is admitted with new-onset atrial fibrillation (A-fib) that triggers acute congestive heart failure (CHF). Both conditions are evaluated, treated, and monitored during the admission. The provider documents both diagnoses clearly in the record, and clinical indicators support the acuity of each. At the coding level, two principal diagnosis (PDX) options are clinically valid: I48.91 (Unspecified atrial fibrillation) results in DRG 310, with a relative weight of 0.553 and a reimbursement of approximately $4,736 I50.9 (Unspecified heart failure) results in DRG 293, with a relative weight of 0.5615 and a reimbursement of approximately $4,795 Although CHF offers a slightly higher payment, it carries added risk in value-based care programs. Coding CHF as the PDX places this case in the CMS Heart Failure 30-Day Readmission Cohort, which is publicly reported and directly impacts a hospital’s readmission scores and star ratings. Coding A-fib, by contrast, avoids triggering that metric. Key takeaway for coders : Don’t make DRG assignment decisions in isolation. Collaborate with CDI and quality teams to understand downstream implications. Even small DRG differentials may lead to long-term financial risk if they adversely impact quality metrics. Be aware of cohort inclusion criteria tied to mortality, complications, and readmissions when selecting the principal diagnosis. When both conditions meet criteria for PDX, and documentation supports either as the focus of care, coders must weigh the immediate DRG return against long-term quality exposure. Query for specificity when it may influence cohort inclusion or risk adjustment, not just DRG grouping. From Code Assignment to Strategic Impact In today’s value-based care environment, coding professionals play a strategic role in shaping financial outcomes, quality performance, and public reporting. Accurate, complete, and specific coding is no longer just about selecting the highest-paying DRG. It is about capturing the full complexity of the patient’s condition, supporting risk adjustment models, and influencing quality domains that determine reimbursement, ratings, and reputation. Coders and CDI teams must operate as clinical and operational stewards, ensuring documentation supports both the clinical reality and the evolving expectations of payers and regulators. The future of hospital success depends on how precisely and thoughtfully each case is coded. Sources Centers for Medicare & Medicaid Services. “Hospital Value-Based Purchasing Program.” CMS.gov CMS Star Ratings Fact Sheet. “Overall Hospital Quality Star Rating.” CMS.gov AHIMA Foundation. “CDI Program Impact Report.” 2023. AHIMA.org Centers for Medicare & Medicaid Services. “2024 Medicare Advantage and Part D Rate Announcement.” CMS.gov Agency for Healthcare Research and Quality (AHRQ). “Elixhauser Comorbidity Index.” AHRQ.gov
The Centers for Medicare & Medicaid Services (CMS) has unveiled a sweeping expansion of its Medicare Advantage (MA) audit program, signaling a significant escalation in federal oversight. Under the new initiative, CMS will conduct annual audits of all 550 eligible MA contracts—a dramatic increase from the roughly 60 plans reviewed each year in the past. Additionally, the agency has committed to clearing a year-long backlog of audits, prioritizing unresolved payment reviews from 2018 through 2024, with a completion deadline set for early 2026. The announcement has sent shockwaves through the healthcare industry and financial markets, triggering swift backlash from major insurers. UnitedHealth Group and Humana—two of the largest Medicare Advantage (MA) providers—are now under heightened scrutiny, with UnitedHealth facing an active U.S. Department of Justice (DOJ) investigation into potential MA billing fraud. In an effort to preempt further regulatory action, both insurers have publicly endorsed reforms aimed at curbing the use of insurer-initiated home risk assessments. A controversial practice linked to inflated Medicare reimbursements. Analysts warn that such changes could reduce Medicare spending by as much as $124 billion over the next decade, dealing a significant blow to insurers that rely on these revenue streams. The expanded Medicare Advantage (MA) audit program marks a seismic shift in regulatory enforcement, fundamentally altering the compliance landscape for insurers and providers. Organizations must now brace for unprecedented documentation scrutiny, rigorous retrospective audits, and a far more aggressive federal oversight regime. To navigate this new reality, compliance programs require immediate reassessment, internal audit processes must be strengthened, and risk-sharing agreements should be reevaluated to mitigate the substantial financial and operational exposures stemming from this heightened oversight. Sources: Centers for Medicare & Medicaid Services. “CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits.” CMS.gov The Wall Street Journal. “Humana, UnitedHealth Back Limits on Medicare Billing Practices That Boost Revenue.” WSJ.com
As artificial intelligence reshapes healthcare, the accuracy and integrity of clinical data have never been more critical. At the heart of this transformation is Clinical Documentation Integrity (CDI), which is the process that ensures patient records are complete, accurate, and reflective of everyone's true clinical picture. CDI is more than a coding or compliance function; it directly influences the quality of data that drives analytics, informs patient care decisions, and feeds AI systems. Without precise documentation, AI models risk learning from flawed or incomplete narratives, which can perpetuate disparities rather than correct them. The quality of AI-driven healthcare is only as strong as the documentation behind it. This makes CDI a foundational element in the conversation about bias, representation, and equity in healthcare data and are issues that become even more urgent as technology plays a larger role in clinical decision-making.
Do these sentiments sound familiar? For those of you working in CDI, Coding, and/or Quality, you are likely aware of the dreaded Patient Safety Indicators (PSIs). For those of you newer to the CDI and Coding community, let’s take a moment to break it down. What are Patient Safety Indicators? PSIs are a set of measurement tools created by the Centers for Medicare & Medicaid Services (CMS) that track adverse patient outcomes. This article in particular focuses on the Inpatient space. Per the Agency for Healthcare Research and Quality (AHRQ), Patient Safety 101, “Safety” can be defined in healthcare as: “avoiding harm to patients from care that is intended to help them. It involves the prevention and mitigation of harm caused by errors of omission or commission in healthcare, and the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur.” 1 Patient safety was not at the forefront of healthcare until the late 1990’s when the Institute of Medicine (IOM) published the report, To Err is Human. This report estimated that nearly 44,000–98,000 patients die from preventable errors in American hospitals each year. 2 The body content of your post goes here. To edit this text, click on it and delete this default text and start typing your own or paste your own from a different source.
HCC RISK ADJUSTMENT
V24 - V28
Are You Ready?
Ensuring your organization makes a successful transition
Learn about the changes and implications of the HCC model transition from V24 to V28, featuring industry experts in medical coding and CDI. We will discuss the changes and implications of the HCC model transition from V24 to V28 and gain actionable insights on navigating challenges, optimizing workflows, and ensuring accurate risk scoring under the new model.
Understanding that risk adjustment is not just HCC but is underlying in everything we do in mid revenue.
Download the Provider Queries 101 article to learn how better documentation practices can have a significant impact on your organization's bottom line.
Explore UASI's comprehensive resource page for valuable insights, tools, and expertise in healthcare staffing, revenue cycle management, and compliance solutions
Definition: Neonatal encephalopathy (NE) is a clinically defined syndrome of disturbed neurologic function in the earliest days of life in a term or late preterm infant, manifested by difficulty with initiating and maintaining respiration, depression of tone and reflexes, subnormal level of consciousness, and often seizures. Clinical presentation: Low APGAR scores and/or weak/absent cry in the delivery room. Hyperalert, irritable, lethargic, obtunded. Decreased spontaneous movements, poor tone, blunted or absent primitive reflexes, seizure activity. Breathing and/or feeding difficulties. Documentation Tips: The CDS should review to identify the underlying etiology . (e.g., hypoxic-ischemic event, infection, metabolic disorder). Review clinical indicators that may indicate associated conditions , such as seizures, abnormal imaging, acidosis, or multi-organ dysfunction. Review the documentation for the timing of onset (e.g., at birth, delayed). Common clinical indicators include low APGAR scores, need for resuscitation, abnormal tone, or altered level of consciousness. ICD-10-CM Coding: P91.811, Neonatal encephalopathy in diseases classified elsewhere P91.819, Neonatal encephalopathy, unspecified Use when the type or etiology of NE is not documented Query Example: To the Attending Neonatologist: Documentation in the medical record indicates the newborn infant delivered from mother with placental abruption demonstrates seizures, abnormal muscle tone, low APGAR scores, and required resuscitation at birth. Imaging showed evidence of cerebral edema. The diagnosis of “neonatal encephalopathy” was documented in the assessment. Query: Based on the clinical indicators, can you clarify the type and cause of the encephalopathy in this newborn? Please select the most appropriate option below or specify another diagnosis: Neonatal encephalopathy due to Hypoxic-ischemic encephalopathy (HIE) Neonatal encephalopathy due to other etiology (please specify) Other (please specify): __________
Definition: Tumor lysis syndrome (TLS) is an oncologic emergency caused by massive tumor cell lysis and the release of large amounts of potassium, phosphate, and uric acid into the systemic circulation. Deposition of uric acid and/or calcium phosphate crystals in the renal tubules can result in acute kidney injury.
Syndrome of Inappropriate Antidiuretic Hormone (SIADH) occurs when the pituitary gland releases excessive antidiuretic hormone (ADH) , leading the body to retain fluid and dilute sodium levels in the bloodstream. This condition causes hyponatremia and hypo-osmolality , often triggering a complex clinical picture. What Causes SIADH? SIADH can develop in response to several underlying conditions or external factors: CNS disturbances: Stroke, hemorrhage, infection, and trauma can trigger abnormal ADH release. Cancer: Especially small cell lung cancer, extrapulmonary small cell carcinomas, head and neck cancers, and olfactory neuroblastomas. Medications: SSRIs, NSAIDs, opiates, some antineoplastic drugs, ciprofloxacin, haloperidol, and high-dose imatinib. Surgery: Often linked to pain response. Hormonal deficiencies: Including hypothyroidism and hypopituitarism. Exogenous hormone use: Vasopressin, desmopressin, and oxytocin. HIV infection Hereditary SIADH Diagnostic Criteria: Schwartz and Bartter Clinical Framework A diagnosis of SIADH typically includes: Serum sodium < 135 mEq/L Serum osmolality < 275 mOsm/kg Urine sodium > 40 mEq/L Urine osmolality > 100 mOsm/kg Normal skin turgor and blood pressure (absence of clinical volume depletion) Exclusion of other hyponatremia causes Correction of sodium levels via fluid restriction Important Note: Code only the SIADH, not the hyponatremia, as hyponatremia is considered integral to the disease process . Clinical Scenario A 68-year-old male presents to the ED with confusion , nausea , and a 12-pound weight gain over the past week. He was diagnosed with small cell lung cancer two months ago. Vitals: BP: 160/90 mmHg HR: 110 bpm Labs: Serum sodium: 122 mEq/L Serum osmolality: Decreased Urine: Elevated osmolality and high sodium concentration Indicators Suggestive of SIADH Hyponatremia: Sodium level of 122 mEq/L Diluted Serum Osmolality: From water retention Concentrated Urine: High osmolality and sodium levels despite low serum sodium Recent Weight Gain: 12 lbs in one week, pointing to fluid overload Underlying Malignancy: Small cell lung cancer is a well-known cause of ectopic ADH production Documentation Tips 1. Accurate Diagnosis Clearly state “SIADH” and link it to the underlying cause , such as cancer. 2. Clinical Findings Review provider and nursing notes for symptoms like confusion, nausea, and fluid retention. Confirm vital signs and weight gain. Include lab values: sodium, serum/urine osmolality, and urine sodium. 3. Treatment Plan Document fluid restriction orders . Check MAR for medications such as vasopressin receptor antagonists . Note any improvements in symptoms and lab values after treatment. Tip: High blood glucose can artificially lower serum sodium levels. Use a sodium correction calculator to determine the true sodium level. References Centers for Medicare and Medicaid Services. (2024). ICD-10-CM Official Coding Guidelines. cms.gov Pinson, R., & Tang, C. (2024). The CDI Pocket Guide. cdiplus.com Prescott, L., & Manz, J. (2024). ACDIS CDI Pocket Guide. acdispro.com Sterns, R. (2024). Pathophysiology and etiology of SIADH. UpToDate. Yasir, M., & Mechanic, O.J. (2023). Syndrome of Inappropriate Antidiuretic Hormone Secretion. StatPearls Publishing.
Understanding Stroke and Its Long-Term Impact Stroke is the third most common cause of disability and the second most common cause of mortality worldwide. The global 30-day fatality rate following an initial ischemic stroke is estimated at 16–23% . A U.S. study of 220 ischemic stroke survivors revealed a range of neurologic deficits at six months post-stroke, including: Hemiparesis (50%) Cognitive defects (46%) Hemianopia (20%) Aphasia (19%) Sensory deficits (15%) Additionally, survivors experienced long-term disabilities such as: Depression (35%) Inability to walk without assistance (31%) Institutionalization (26%) Bladder incontinence (22%) What is a Stroke? A stroke , also known as a cerebrovascular accident (CVA) , occurs when the blood supply to part of the brain is interrupted or reduced , preventing brain tissue from receiving oxygen and nutrients. As a result, brain cells begin to die within minutes . Types of Strokes Ischemic Stroke The most common type, accounting for approximately 87% of all strokes. It occurs when a blood clot blocks or narrows an artery leading to the brain. Hemorrhagic Stroke Occurs when a blood vessel in the brain bursts , leading to bleeding in or around the brain . Common Late Effects of CVA Physical: Hemiplegia, hemiparesis, dysphagia, ataxia Cognitive: Memory loss, attention deficits, executive function impairments Speech and Language: Aphasia, dysarthria Sensory: Visual field loss, neglect (lack of awareness of one side of the body) Emotional and Behavioral: Depression, anxiety, personality changes Other: Bladder and bowel control issues, fatigue Recrudescence of Stroke Symptoms Recrudescence refers to the reappearance of previously resolved neurological deficits from a prior stroke. These symptoms are typically mild , short-lived , and not due to a new stroke . Key considerations: Recrudescence is coded as a “late effect of stroke.” Follows the same coding and sequencing guidance as the principal diagnosis (PDX). Can be reported alongside a new acute infarction , if applicable. Clarity in documentation is essential to accurately capture the etiology of stroke-related symptoms— query the provider if necessary. Query Example for Clarification Dear Dr. Carlson , Patient with PMH of CVA. Per H&P, admitted with “dysphagia.” Other diagnoses include severe malnutrition, with plans for a PEG tube. Can this patient’s dysphagia be specified as the most likely cause? For example: Dysphagia is recrudescence of previous stroke Dysphagia related to other (please specify) ___ Unknown/undetermined Other clinical indicators/treatment from the patient’s record: H&P notes: “dysphagia, severe malnutrition, and failure to thrive. ST/PT/OT to see. Family thinks dysphagia has been going on for a while.” Treatment: RD consult, PEG tube placement, PT/OT/ST Why It Matters: A favorable query response could shift the DRG from DRG 392 (Esoph, gastro, and misc digestive disorders w/o MCC) with the PDX of dysphagia , to DRG 057 (Degenerative nervous system disorders w/o MCC) with the PDX of weakness/dysarthria as a late effect of CVA .
Stay ahead with UASI Coding Tips section, featuring practical advice, industry updates, and best practices to enhance your coding accuracy and efficiency.
Many coders still struggle with assigning the seventh character for initial and subsequent encounters. Using these correctly ensures accurate reimbursement and avoids claim denials. When assigning the 7th character for injuries or conditions like fractures, sprains, or open wounds, do not confuse “initial” with the patient’s first visit. Initial Encounter (A) = Active treatment is still being provided – “surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.” Subsequent Encounter (D) = The patient is in the healing or recovery phase, receiving routine follow-up care - “cast change or removal, an X-ray to check healing status of fracture, removal of an external or internal fixation device, medication adjustment, and other aftercare and follow-up visits following treatment of the injury or condition.” In ICD-10-CM, “initial” vs. “subsequent” is about the type of care being provided, not the location (like inpatient vs. outpatient) Use 7th character “A” (Initial Encounter) when the patient is receiving active treatment for the injury – regardless of whether they’re in the ER, surgery, or admitted inpatient. Use 7th character “D” (Subsequent Encounter) once the patient is receiving routine aftercare for healing – even if they are still in the hospital (e.g., rehab or post-op management).
Optilume is an FDA approved drug-coated balloon, developed by Urotronic, that is inserted via cystoscopy to dilate and treat urethral strictures or stenosis caused by benign prostatic hyperplasia (BPH). It is a minimally invasive procedure that provides immediate relief from the urinary symptoms men can experience with BPH. A CPT code, 52284, was introduced in 2024 which can be used when a cystoscopy with Optilume is performed. The drug on the outer surface of this balloon (paclitaxel), once absorbed, may help maintain the stricture expansion and help improve urinary flow. The balloon is not left inside the patient, but rather taken out after 5 minutes of inflation, leaving the drug to do its job with the rest. Key Points for Coders Use CPT 52284 only when a drug-coated balloon (like Optilume) is used during cystoscopy to treat urethral stricture/stenosis. Documentation must clearly state: Use of Optilume Paclitaxel drug delivery Balloon inflation and removal Do not code separately for the drug Use C1889 for the device code Ensure the diagnosis supports stricture/stenosis, not just BPH. This code is new in 2024—don’t use it for earlier dates. Watch for bundling and use modifiers only if appropriate. Check payer policies for coverage and authorization requirements References: Optilume BPH Catheter System – P220029 | FDA Optilume Optilume® for Urethral Stricture | Urethral Drug Coated Balloon CPT Assistant, February 2024, Volume 34, Issue 2, page 21 Coders Desk Reference
By now, you’ve all seen and coded a leadless pacemaker. Did you know they make dual-chamber leadless pacemakers?
Myocarditis is a condition where the heart muscle becomes inflamed. It is most commonly caused by an infection in the body, such as a viral infection (including those that cause the common cold, influenza or COVID-19), bacterial infection (such as diphtheria or strep), or fungal infection (such as candidiasis). In severe cases, myocarditis may lead to stroke, heart attack, heart failure or death.
Sign up to receive monthly CDI & Coding Tips directly to your inbox!
Now Hiring Remote Healthcare Roles
Join UASI and make an impact from home with flexible, stable, and well-supported career opportunities.
CDI Specialist (RN) · CDI Auditor · CDI Second Level Reviewer · Coding Manager · Senior Inpatient Coder · OP Profee Coder · ED Remote Coder
Are you ready
to take the next steps?
Apply now and let's see if it's a good fit!
UASI is an Equal Opportunity/Affirmative Action Employer
