Enhance Your Accuracy with Expert Coding Tips

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 January 2025. The focus is on outpatient initiatives related to HIM coding and documentation requirements and is not intended to review every active work plan item. For each relevant initiative, a summary of the OIG or RAC compliance concern, the month and year published and added to the plan, and related coding and documentation requirements is included below. More importantly, for each outpatient initiative presented, UASI has included specific suggested compliance activities to assist our clients with their ongoing compliance efforts. The information below includes an analysis of the following active outpatient topics: · Medicare Payments for Lower Extremity Peripheral Vascular Procedures (OIG) · Medicare Part C Audits of Documentation Supporting Specific Diagnosis Codes (OIG) · Audits of Medicare Part C Health Risk Assessment Diagnosis Codes (OIG) · Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (RAC) · Transurethral Waterjet Ablation of the Prostate for Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms (LUTS) (RAC) · Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (RAC) Medicare Payments for Lower Extremity Peripheral Vascular Procedures, June 2024 Minimally invasive procedures aiming to improve blood flow when arteries narrow or become blocked because of peripheral arterial disease have been identified by CMS and whistleblower fraud investigations as vulnerable to improper payments. OIG will analyze Medicare fee-for-service for peripheral vascular procedures for questionable characteristics and review the program integrity activities of CMS and its contractors to combat fraud, waste, and abuse specific to these procedures. Additionally, these procedures will be assessed to ensure compliance with CMS requirements and meet applicable treatment guidelines. Documentation should include: · A description of the studies performed, and any contrast media and/or radiopharmaceuticals used · Any patient adverse reactions and/or complications · Normal and abnormal findings and comparison with prior relevant studies · Variations from normal should be documented along with measurements. · The report should address or answer any specific clinical questions. · Results of all testing must be shared with the referring physician · Adequate documentation to support medical necessity of performing non-invasive vascular studies · medically necessary follow-up noninvasive vascular studies post-angioplasty is dictated by the vascular distribution treated CMS expects that non-invasive vascular studies are not performed more than once a year. A complete review of billing and coding requirements, including the CPT codes and an extensive list of ICD-10-CM codes that support medical necessity can be found at Article - Billing and Coding: Non-Invasive Peripheral Arterial Vascular Studies (A57593) (cms.gov) Medicare Part C Audits of Documentation Supporting Specific Diagnosis Codes, November 2023 This is the first of two workplan items focusing on high-risk diagnoses that might result in inaccurate risk adjusted data. The first item focuses on quality of the documentation supporting the diagnoses and the second item: Nationwide Audits of Medicare Part C High-Risk Diagnosis Codes focuses on code accuracy, Payments to Medicare Advantage (MA) organizations are risk-adjusted based on each enrollee's health. Inaccurate diagnoses may cause CMS to pay MA organizations improper amounts. In general, MA organizations receive higher payments for enrollees with more complex diagnoses. CMS estimates that 9.5 percent of payments to MA organizations are improper, mainly due to unsupported diagnoses submitted by MA organizations. Prior OIG reviews have shown that some diagnoses are more at risk than others to be unsupported by medical record documentation. We will perform a targeted review of these diagnoses and will review the medical record documentation to ensure that it supports the diagnoses that MA organizations submitted to CMS for use in CMS's risk score calculations and to determine whether the diagnoses submitted complied with Federal requirements. Nationwide Audits of Medicare Part C High-Risk Diagnosis Codes, November 2023 Medicare Advantage (MA) organizations receive risk-adjusted reimbursement based on the health status of each enrollee. All MA organizations submit risk-adjustment data to CMS according to defined regulations. Mis-coded diagnoses can result in incorrect payments back to MA organizations. These audits will focus on identified high risk diagnoses being mis-coded and resulting in increased risk-adjusted payments from CMS. In a previous CMS audit of high-risk diagnoses, 183 of the 280 sampled enrollee-years, resulted in the following findings: 1) the medical record(s) provided did not support the diagnosis code(s) or 2) the medical record(s) could not be located; therefore, the diagnosis code(s) was not validated. [3] Through data mining techniques and meetings with medical professionals, CMS identified diagnoses that are at a higher risk of being miscoded. These diagnoses include: · Major depressive disorder: Concerns related to this diagnosis note that the diagnosis was documented but the patient did not have an antidepressant medication prescribed. As such, a major depressive disorder may not be supported in the documentation. · Acute stroke: Findings for this diagnosis noted that an acute stroke diagnosis on a physician claim during a service year does not correspond to an inpatient or outpatient hospital claim. · Vascular claudication: The vascular claudication findings noted a diagnosis during the service year which was not present during the preceding 2 years. · Cancer: Findings related to several cancer diagnoses in this audit were related to a cancer diagnosis during the service year, however no treatment (e.g., surgery, radiation, or chemotherapy) was found within a 6-month period before or after the diagnosis. A diagnosis of history of cancer may be more appropriate. These cancer diagnoses include: o Breast cancer o Colon cancer o Prostate cancer o Lung cancer · Acute myocardial infarction (AMI): These specific findings noted diagnoses of acute myocardial infarction on a physician or outpatient claim during the service year. However, there was not an AMI diagnosis on a corresponding hospital claim. A code for the history of MI may be more appropriate. · Embolism: Enrollees received a diagnosis of acute or chronic embolism without an anticoagulant medication, which is typically used to treat an embolism. The history of embolism diagnosis may be more appropriate. These findings confirm the CMS intention to continue auditing for and enforcing complete and accurate clinical documentation. UASI Suggested Compliance Activities for this Initiative 1. Improve population health data analytical capabilities and monitor high risk diagnosis reporting. 2. Utilize reports to determine the frequency of these high-risk diagnoses associated with risk-adjustment enrollees. Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint, June 2023 Documentation will be reviewed to determine whether minimally invasive surgical fusion of the sacroiliac joint met Medicare coverage criteria and was reasonable and necessary. The only code included in this review is CPT code 27279, Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device. Additional procedure coding information can be found in the CPT Assistant, April 2023, Volume 33, Issue 4, page 16. There are multiple different ICD-10-CM diagnosis codes that support the medical necessity for this procedure. ICD-10-CM Diagnosis Code Code Description M43.27 Fusion of spin, lumbosacral region M43.28 Fusion of spin, sacral and sacrococcygeal region M46.1 Sacroiliitis, NEC M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region M53.2X7 Spinal instabilities, lumbosacral region M53.2X8 Spinal instabilities, sacral and sacrococcygeal region M53.3 Sacrococcygeal disorders, NEC M533.87 Other specified dorsopathies, lumbosacral region M53.88 Other specifies dorsopathies, sacral and sacrococcygeal region M99.14 Subluxation complex (vertebral) of sacral region S33.2XXA Dislocation of sacroiliac and sacrococcygeal joint, initial encounter S33.2XXD Dislocation of sacroiliac and sacrococcygeal joint, subsequent encounter S33.2XXS Dislocation of sacroiliac and sacrococcygeal joint, sequela S33.6XXA Sprain of sacroiliac joint, initial encounter S33.6XXD Sprain of sacroiliac joint, subsequent encounter S33.6XXS Sprain of sacroiliac joint, sequela S33.8XXA Sprain of other parts of lumbar spine and pelvis, initial encounter S33.8XXD Sprain of other parts of lumbar spine and pelvis, subsequent encounter S33.8XXS Sprain of other parts of lumbar spine and pelvis, sequela Coverage Indicators [4] This procedure is considered medically necessary when ALL the following criteria are met: · Have moderate to severe pain with functional impairment and pain persists despite a minimum six months of intensive nonoperative treatment that must include medication optimization, activity modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ, and hip including a home exercise program · Patient’s report of typically unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized over the posterior SIIJ, and consistent with SIJ pain · A thorough physical examination demonstrating localized tenderness with palpation over the sacral sulcus in the absence of tenderness of similar severity elsewhere and that other obvious sources for their pain do not exist · Positive response to a cluster of 3 provocative tests · Absence of generalized pain behavior · Diagnostic imaging studies that include ALL the following o Imaging (plain radiographs and a CT or MRI) of the SI joint that excludes the presence of destructive lesions, fracture, traumatic SIJ instability, or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion. o Imaging of the pelvis (AP plain radiography UASI Suggested Compliance Activity for this Initiative 1. Utilize reports to determine the frequency of CPT code 27279. 2. Based on these findings, determine the need to audit a percentage of the total cases. Transurethral Waterjet Ablation of the Prostate for Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms (LUTS), April 2023

We’re excited to announce the release of our 2025 HCC Passport! The updated version offers over 35 pages of critical documentation tips, all derived from UASI outpatient audit findings across the country. This comprehensive guide is packed with actionable insights to help healthcare providers: ✅ Capture the specificity of diagnoses ✅ Improve quality metrics ✅ Identify chronic conditions for accurate HCC coding ✅ Ensure accurate reporting of procedures At UASI Outpatient CDI Solutions, we combine deep clinical expertise and coding precision to help you navigate the complexities of HCC capture in real time. Ready to level up?

Obesity: Understanding the Condition and Its Implications Definition: • Obesity: A state of excess storage of body fat. • Overweight: Refers to excess body weight for height. Facts and Statistics: The Centers for Disease Control (CDC) reported in August 2024 that more than 100 million U.S. adults aged 20 or older have obesity, with 22 million classified as severely obese. Additionally, 14.7 million cases of obesity have been reported in U.S. children and adolescents aged 2-19. The National Center for Health Statistics shows that the obesity prevalence in adults (aged 20 and older) rose from 19.4% in 1997 to 31.4% by the reporting period of January-September 2017. Diagnostic Criteria: • Underweight: BMI < 18.5 kg/m² • Normal Weight: BMI 18.5–24.9 kg/m² • Overweight: BMI 25–29.9 kg/m² • Obesity (Class 1): BMI 30–34.9 kg/m² • Obesity (Class 2): BMI 35–39.9 kg/m² • Extreme Obesity (Class 3): BMI > 40 kg/m² Note: Morbid obesity is defined by a BMI > 40 kg/m², or a BMI of 35 or higher with at least one weight-related comorbidity, such as diabetes, heart disease, stroke, hypertension, or arthritis. Diagnostic Tests: • Fasting Lipid Panel • Liver Function Studies • Thyroid Function Tests • Fasting Glucose and Hemoglobin A1c (HbA1c) Treatment: • Nutritional consult • Counseling on diet and exercise • Medications such as GLP-1s • Bariatric surgery procedures • Treatment for associated comorbid conditions ________________________________________ Coding and CDI Considerations: • Overweight and obesity codes are found in category E66. An instructional note directs the reporting of BMI, if known, as an additional diagnosis (adults: Z68.1-Z68.45; pediatrics: Z68.5-). • Code E66.01 classifies morbid (severe) obesity due to excess calories. Documentation of "severe" obesity allows the assignment of this code. However, E66.01 has an Excludes1 note that it should not be coded with E66.2, which refers to morbid obesity with alveolar hypoventilation. • BMI codes can be taken from non-physician documentation, but the physician must provide an associated diagnosis. IPPS FY 2025 New Codes for Obesity: • E66.811 Obesity, Class 1 • E66.812 Obesity, Class 2 • E66.813 Obesity, Class 3 (synonymous with morbid obesity) • E66.89 Other obesity, not elsewhere classified Current coding guidance states that obesity and morbid obesity are always clinically significant and should be reported when documented. No additional documentation is required to support clinical significance for this condition (such as evaluation, treatment, or increased monitoring). Obesity and Comorbid Conditions: CDI specialists should review for obesity-related comorbid conditions, such as: • Obstructive sleep apnea (OSA) • Malignancy • Coronary artery disease (CAD) • Hypertension (HTN) • Gallbladder disease • Osteoarthritis • Diabetes • Stroke • Depression If the patient's BMI is 35 or higher and they have a comorbid condition related to obesity, this may be considered morbid obesity. The provider should document the relationship between weight and the comorbid condition to demonstrate the need for specific management and strengthen medical necessity and decision-making. Obesity also impacts risk adjustment methodologies, including Elixhauser and AHRQ PSIs. Query Example: Please specify if the condition you are managing can be represented as: • Morbid Obesity • Obesity, Class 2 • Other condition (please specify) The following clinical indicators are noted in documentation: • RN admission assessment with BMI 38.5 • Nutrition consult ordered • Chronic conditions of Type II Diabetes and Hypertension References: • AHA Coding Clinic 2018 Fourth Quarter, p. 77 • Hamdy, O. (2024). Obesity. Medscape. www.medscape.com • Official Coding Guidelines Sections I.C.19.a and I.C.19.c • Pinson, R., Tang, C. (2024). Body Mass Index and Obesity. CDI Pocket Guide. CDIPlus • Prescott, L., Manz, (2024). Morbid Obesity. ACDIS Pro • US Centers for Disease Control and Prevention. New CDC Data Show Adult Obesity Prevalence Remains High. CDC. Available at https://www.cdc.gov/media/releases/2024/p0912-adult-obesity.html . September 12, 2024; Accessed: November 26, 2024.

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

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

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

The accurate classification and documentation of diseases are key, especially in the case of neoplasms. The importance of precise diagnosis coding cannot be overstated. With advancements in medical knowledge and technology, understanding the intricacies is crucial for healthcare professionals striving to provide optimal care for their patients.

CKD as defined by NKF KDOQI: Kidney damage for >3 months defined by structural or functional abnormalities of the kidney that can lead to decreased GFR • For CKD to be diagnosed, one of the following criteria must be present for >3 months: GFR <60, or Clinical markers of kidney injury with objective findings such as: Albuminuria, abnormal urine sediment, electrolyte abnormalities due to renal tubular disorders, histological and structural abnormalities, or history of renal transplant • CKD stage is determined by the stable GFR: Stage GFR >90 60-89 3a 45-59; 3b 30-44 15-29 <15 ESRD Dialysis-dependent stage 5 Important note: GFR in stages 1 and 2 is >60 which does not meet the first criterion, so a diagnosis of CKD would require at least one clinical indicator of kidney injury Provider documentation should be clear if there is a causal relationship related to the CKD to determine the most accurate code assignment. For example, a patient is admitted with diabetes, hypertension and CKD and the provider links the CKD to the diabetes. A causal relationship is indicated and denotes the CKD is not related to the hypertension. Only a code for diabetic CKD would be reported. Hypertension would be reported separately. CKD should not be coded as hypertensive if the physician has specifically documented a different cause. Provider documentation noting only the presence of comorbid conditions and CKD would capture a cause and effect relationship between the conditions. For example, a patient is admitted with chronic comorbidities noted as diabetes, hypertension and CKD. A cause and effect relationship are presumed, and the CKD is most likely related to both hypertension and diabetes. Assign codes: Type 2 diabetes mellitus with diabetic chronic kidney disease Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease Chronic kidney disease, unspecified Provider documentation should be clear related to a kidney transplant status and CKD. For example, a patient admitted to the hospital has kidney transplant failure with CKD 4. Principal diagnosis would be Kidney transplant failure, for complication of the transplanted kidney. Chronic kidney disease stage 4 would be coded as a secondary diagnosis. Additional Tips: Correct documentation of CKD stage is important- stages 4 and 5 without HD are CCs. If the stage is not documented and stable creatinine levels are present, providers should be queried for patients with a GFR < 60. If the patient’s history presents competing etiologies for the documented CKD (for example-a patient with polycystic kidney disease and hypertension), a query is likely required for accurate code assignment. The Official Guidelines for Coding and Reporting state that chapter-specific guidelines from Chapter 9 and 14 direct reporting of combination codes r/t CKD, hypertension, and diabetes. The classification presumes a causal relationship between CKD and the conditions of hypertension and heart failure. If the provider indicates the CKD is not related to the hypertension and/or heart failure, the combination code would not be assigned. A code from category N18 should also be assigned for the specific stage of CKD. The Official Guidelines for Coding and Reporting states that patients with a history of renal transplant should have CKD staged per the eGFR. The presence of CKD is not considered a complication. Both the specific N18 code and the Z94.0 code for kidney transplant status would be assigned. The providers documentation of CKD G4A3 is synonymous with stage 4 CKD and would code to N18.4 per Coding Clinic First Quarter 2023.  References: Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2018: page 88. Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2020: page 35. Coding Clinic for ICD-10-CM/PCS, First Quarter 2023: page 17. Prescott, L. & Manz, J. (2020). 2021 ACDIS Pocket Guide. The Essential CDI Resource. HCPro, 323-328. Pinson, R. & Tang, C., (Jan, 2021). Filtering Out Confusion over Kidney Disease. Retrieved from Filtering Out Confusion Over Kidney Disease | Pinson & Tang (pinsonandtang.com)