40 Years of Delivering Outcomes
We partner to bridge the gap between clinical, financial and operational people and processes impacting quality outcomes and improving organizational sustainability.
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.
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.
CODING SERVICES
Achieve accurate, compliant, and efficient coding with our professional coding services, supporting inpatient, outpatient, and specialty coding needs with UASI.
RISK BASED SERVICES
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.
CDI SERVICES
UASI enhances the accuracy and completeness of your clinical documentation, ensuring compliance and optimal reimbursement through our expert CDI services.
DENIALS & REVENUE INTEGRITY
Maintain financial health and compliance with UASI's comprehensive revenue integrity services, including auditing, denials management, and process optimization.
“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
Explore UASI's comprehensive resource page for valuable insights, tools, and expertise in healthcare staffing, revenue cycle management, and compliance solutions
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
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.
When you think about coding in your organization, do you consider it a cost center? Often, the direct costs such as salaries, benefits, and equipment dominate the conversation. But what if we shifted the focus to understanding coding as an essential investment in your healthcare operations rather than just another expense? Beyond the Obvious Costs: The Hidden Impact of Coding We often focus on direct costs, but it’s easy to underestimate the indirect ones that quietly accumulate. Supervisory time, for example, is often overlooked as an indirect cost. Recruiting, testing, and turnover contribute further, along with quality assurance, ongoing education, and training. With every regulatory change and code-specific nuance, the demands increase—requiring more time, resources, and money. These factors don’t just affect your bottom line; they can significantly impact your Return on Investment (ROI) in ways that are frequently underestimated. The Real ROI of Accurate Coding The accuracy of your coding has a direct influence on your organization's financial health. Consider this: what would a mere 1% increase in coding accuracy mean for your top line? Not only could it boost revenue, but it could also reduce re-work costs and significantly cut down on denials. A lower denial rate means faster cash flow, less time spent on rework, and fewer headaches. Many systems often handle coding internally, focusing only on the direct costs. However, this approach overlooks not only the significant indirect costs—like supervisory time and training—but, more importantly, the impact on accuracy and productivity. These hidden factors can make a big difference in overall performance, which is why outsourcing your coding can provide a more efficient and accurate solution. *“If you are questioning to remain in-house or outsource, it is imperative that you consider all costs and rewards – coding was costing me about $400k per month in lost revenue due to improper coding and lost charges (on $116m gross revenue, now $230m, so it would be higher).” Shifting Focus: From Administration to Patient Care What if your team could focus on what really matters—patient care—without the administrative burden of coding? Imagine the impact on your organization if you could shift the focus from managing coding staff and processes to enhancing patient outcomes. 6 Key Reasons to Outsource Your Coding Outsourcing your coding might be the game-changer your organization needs. Here’s why: Coder Shortage: The ongoing shortage of experienced coders, exacerbated by factors like ICD-10 implementation and the COVID-19 pandemic, makes finding and retaining qualified staff increasingly difficult. Quality and Productivity Demands: With evolving healthcare technology and constant regulatory changes, coding has become more complex. Meeting productivity and quality standards is challenging, especially for in-house teams. Fluctuating Workloads: Your coding needs fluctuate, but your costs don’t have to. Outsourcing allows you to scale up or down based on demand, saving you from the expenses of overstaffing or temporary hires. Geographical Challenges: Whether you're in a rural area or an underserved urban zone, outsourcing circumvents the difficulties of local recruitment by offering a broader talent pool. Improved Data Outcomes: Accurate and efficient coding is crucial for improving key data metrics that impact your organization’s reputation and reimbursement. By outsourcing your coding, you can enhance outcomes related to Health Grades, Quality Scores, CMS Star Ratings, and Risk Adjustment Factor (RAF) scores. Financial Relief: Outsourcing reduces the burden of managing an internal coding department. It cuts costs associated with recruitment, education, training, and retention, allowing you to focus resources where needed—patient care—and improves your overall ROI. *“We know it takes at least 18 months to get a coder proficient and accurate. I know our cost of labor is extremely high and would cost us considerably more per FTE when opportunity costs are calculated (lost revenue due to coding errors, missed charges, education, CDI, etc.)” Challenges and Opportunities: Beyond Just Numbers It’s not only about costs. The workforce is changing, and managing people is becoming harder. Burnout among coding staff is real, and it’s a growing concern that impacts both productivity and quality. Additionally, the coding workforce is aging, with many experienced coders approaching retirement. This looming wave of retirements is likely to exacerbate existing staffing challenges, making it even more difficult to maintain a fully staffed and skilled team. Continuous learning and development aren’t just nice-to-haves—they’re critical to success. As the demands on your coding team increase, are your leaders equipped to manage these challenges? UASI’s Solution: Experience and Expertise at Your Service This is where UASI comes in. With over 40 years of experience, we’ve honed our processes to deliver better results at the same or even lower cost than maintaining an in-house team. Here’s how we can transform your operations: • Reduced Headaches: We take on the challenges of recruiting, training, and managing coding staff, so you don’t have to. • Flexibility and Expertise on Demand: We provide the expertise you need when you need it, allowing you to scale up or down based on your coding demands. • Shared Success: We work as partners, with a focus on shared success and accountability. • Focus on What Matters: Our services free up your team to focus on patient care, reducing in-house tension and administrative strain. Highlighting the Benefits of Outsourcing Coding *“With a coding outsource, organizations do not need to spend money, time, and resources in hiring, training, and retaining experienced coders. Outsourcing is a cost-effective solution to reducing an organization’s administrative costs, as well as decreasing the administrative strain in the HIM department. In consideration of a coding outsource, it’s important to develop a cost-benefit analysis as well as determining appropriate, reportable KPIs.” “As I make changes to the RCM, one constant will be UASI because of their expertise and because of how they work with everyone on my side to effectively train my staff and to educate my providers.” Proven Outcomes: A Client Success Story Outsourcing of coding services has shown remarkable outcomes in terms of improved efficiencies and financial performance. Here are some notable results from a specific outsourcing client: • Decrease in DNFB by 44% in 90 days • Decrease in DNFC by 64% in 90 days • Nearly 100% decrease in front-end claim edits, with coders resolving edits concurrently at the time of coding, leading to an increase in clean claims being released for billing sooner. • Increased productivity, with all coders meeting or exceeding established productivity standards. • Improved efficiency of the organization’s HIM staff, allowing them to focus on resolving EMR issues, obtaining needed provider documentation, addressing chargemaster issues, and other registration and billing challenges. Outsourcing guarantees a qualified team to manage and perform the daily work associated with all coding needs, leading to measurable outcomes like improved DNFC and DNFB, enhanced coding quality, decreased coding edits, reduced denials, improved cash flow, and overall increased departmental efficiency. Flexible Engagement Models: Designed for Your Success At UASI, we offer two flexible ways to engage with our services: • Monthly Subscription Fee to Shared Success Fee: We start with a straightforward monthly subscription, transitioning to a shared success fee model after six months. This approach allows for a seamless transition to outsourcing, where we can re-badge your existing staff where appropriate. After the initial period, we evaluate the success of the engagement, ensuring it aligns with your goals and expectations. • Quick Results and Strategic Planning: Our model enables you to take quick action and see results rapidly. We begin with a thorough assessment to identify potential opportunities, propose a combination of a monthly fee and a shared success model, and allow your health system to evaluate the program for optimization. This data-driven approach ensures that you can determine the best path forward based on both strategy and measurable outcomes. These flexible engagement models are crafted to provide immediate benefits while allowing you to refine your strategy over time. By partnering with UASI, you can be confident in a solution that meets your organization's specific needs, enabling you to focus on what matters most—delivering exceptional patient care while achieving financial success. *CEO, West Coast Health System
“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.
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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