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

Taxpayers spend an average of $2.5 trillion overall for healthcare in the United States as the healthcare industry continues to face complex challenges in the coming year. While this is happening, providers feel the growing financial burden as tensions continue to rise between payers and providers. Understanding the current landscape will allow organizations, providers, and payers to proactively prepare their internal processes to meet industry needs and standards. As a reference point, in January 2024, national health spending grew by 6.0% since January 2023 and represented 17.4% of GDP. Nominal GDP in January 2024 was 5.1% higher than in January 2023, growing more than 0.8 percentage points more slowly than health spending. The Health Research Institute (HRI) of Price Waterhouse Cooper recently predicted 2025 to have the highest medical cost trend in 13 years. HRI asserts that this trend is “driven by inflationary pressure, prescription drug spending and behavioral health utilization”. Even with the rising cost of healthcare, there is a decrease in overall revenue. What CFOs should be aware of is that this financial pressure will affect cash flow, reimbursement rates, and the ability to maintain margins. Each day, we’ll be highlighting a critical area that mid-revenue cycle leaders should prioritize to prepare for these market shifts and reduce revenue leakage in 2025. The 5 areas we’ll cover include: #1 SDoH and Reimbursement Impact #2 Tackling the Growing Threat of Claim Denials #3 Avoid Costly Recoupments & Identify Missed Reimbursement Opportunities #4 Harnessing Artificial Intelligence #5 Reduce Penalties Through Accurate PSI Reporting #1 Social Determinants of Health (SDoH) & Reimbursement Impact The current focus on Social Determinants of Health (SDoH) will continue into 2025. The Inpatient Prospective Payment System (IPPS) final rule provided some good news related to SDoH. CMS plans to increase the federal standard rate by 2.9%. Part of this increase is a change in severity assignment for some SDoH codes. Specifically, treatment plans or encounters related to inadequate housing or housing instability will become a CC (Comorbidity Code) in 2025. The rationale for the changes in severity is due to the anticipated higher than average resource costs associated with these patients. According to the U.S. Department of Health and Human Services, “In the FY 2024 IPPS final rule, CMS finalized a policy change to recognize the higher costs that hospitals incur when they provide hospital services for individuals experiencing homelessness. Building on this policy and the Biden-Harris Administration’s initiative to address unsheltered homelessness, CMS is taking an additional step to better account for the resources involved in furnishing care to individuals experiencing housing insecurity, meaning that hospitals will generally receive higher payments when a patient is experiencing housing insecurity.” Healthcare leaders in the mid revenue cycle can reduce revenue leakage by focusing on accurate documentation and coding of SDoH. In particular, accurate documentation related to housing insecurity should be a critical focus as the 2025 IPPS changes will increase reimbursement rates for these patients. Accurate documentation of SDoH codes will not only improve reimbursement but also help address the higher resource costs associated with treating this patient population. Read our recent article on SDoH to learn more! SDoH Can Make a Big Difference in Patient Care and Reimbursement #2 Tackling the Growing Threat of Claim Denials As we move into 2025, claim denials are expected to remain a significant challenge for healthcare providers and organizations. Denied claims disrupt cash flow, create additional administrative burdens, and can even impact the quality of patient care. According to a recent survey by Experian Health, 38% of healthcare professionals reported that one in every ten claims is denied, while 73% noted that denials rates are on the rise. This increase of denials is putting additional strain on already overburdened healthcare systems and making it harder for providers to maintain operational efficiency. Most healthcare systems are struggling to address the growing volume of claim denials, and because of the administrative burden, fixing the root cause is often overlooked. With increasing claim volumes and complex payer requirements, healthcare providers are overwhelmed by the sheer number of denials in addition to the need to meet multiple deadlines for denials appeals. Compounding this challenge is the lack of specialized expertise in handling claim denials, which makes organizing the workflow and managing the appeals process difficult. Healthcare organizations that fail to address their claim denials are left vulnerable to revenue leakage through missed opportunities for reimbursement. Conducting a denials program assessment is a necessary first step in understanding the root causes of denials and identifying areas for improvement. An assessment can help organizations gain insight into denials trends, develop targeted strategies to reduce denials, and identify ways to implement more efficient workflows. Additionally, an assessment can help identify where education and training are needed to improve accuracy and prevent denials altogether. Many systems find it difficult to even address all the denials as they come in, so they find it challenging to conduct an assessment. Partnering with a third-party authority can help with capacity to get an assessment completed but also provide an objective perspective. In addition, an outsource partner and/or implementing A.I. can help alleviate the burden and cover more volume. An assessment can help identify the best options to solve the problem. #3 Avoid Costly Recoupments & Identify Missed Reimbursement Opportunities In 2024, the Office of Inspector General (OIG) identified several areas in healthcare billing that could cost the American taxpayers billions of dollars in recoupments. To note, the OIG conducts audits to ensure that healthcare claims are compliant with federal regulations. For example, one of the significant findings from the OIG in 2024 was noncompliance with the “two-midnight rule”, which requires a patient’s hospital stay to span two midnights to qualify for inpatient payment. In 2025, OIG audits are expected to continue focusing heavily on validating claims data, ensuring accurate code assignment, and confirming that clinical documentation supports medical necessity. Healthcare systems must prepare for increased scrutiny of their claim’s data. Without a process in place to identify discrepancies in documentation early on, healthcare providers risk triggering unnecessary OIG audits, which could result in costly recoupments. Often, third-party audits are conducted too late once discrepancies have already led to compliance issues and financial loss. This reactionary approach can be avoided by completing preemptive reviews and audits before an official OIG audit occurs. To stay ahead, healthcare organizations must shift their mindset from a reactive to a proactive approach. By conducting regular, ongoing audits or reviews, providers can identify risks and address pitfalls before they escalate into major compliance issues. Furthermore, healthcare systems who elect to conduct proactive 3rd party audits, should view them not merely as a tactic to avoid OIG audits, but as a larger, strategic move to boost ROI by ensuring accurate coding and reimbursement opportunities. Preliminary audits arm healthcare systems with the information and resources to comply with federal regulations while discovering opportunities for increased revenue. #4 Harnessing Artificial Intelligence In utilizing vast amounts of data, A.I. can be harnessed to increase productivity. With these advancements and their impact on the revenue cycle, it is leaving industry experts wondering how the function of accurate code assignment will look in the future. In addition, for smaller healthcare organizations with lower patient volumes, the adoption of A.I. may seem out of reach. This leaves many leaders in the mid revenue cycle uncertain about how to begin integrating these technologies into their operations. As the technology develops and improves, A.I. has the potential to reduce administrative burdens and address the complexity of billing and coding accuracy while improving patient care. These potential improvements could impact the financial health and sustainability of hospitals and physician groups nationwide. To combat healthcare’s rising costs, increase in payer denials, and the need for accurate code assignment, the integration of AI into the revenue cycle will likely become a key competitive differentiator for healthcare organizations in 2025. While the integration of A.I. in CC (Code Capture) has become more widespread, the technology often requires significant volume, so many smaller healthcare facilities have yet to benefit. In addition, the more complex aspects of coding still require human oversight and expertise. The challenge that many health systems face is in regard to identifying the right tool and how to begin integrating new tools into an already established workflow. Partnering with firms that can assist in evaluating AI tool options, help healthcare facilities manage the people processes, and develop the roadmap associated with these new technologies to ensure ROI, is worth consideration. Short term spend for long-term benefits. #5 Reduce Penalties Through Accurate PSI Reporting Patient Safety Indicators (PSIs) are a set of measurement tools developed by the Centers for Medicare and Medicaid Services (CMS) to track adverse patient outcomes, such as hospital-acquired infections, falls, and other complications. These indicators are used to assess the quality of care provided by hospitals and highlight areas where patient safety can improve. Hospitals are required to report PSIs to CMS as part of their participation in Medicare and Value-Based Care programs. PSIs directly impact revenue through penalties and reduced reimbursements. Hospitals with high rates of hospital-acquired conditions are penalized with lower reimbursements, particularly if they rank in the bottom 25% of PSI 90 scores. Despite improvements in PSI reporting, CMS consistently penalizes the lowest performing facilities. In addition, as the healthcare industry continues shifting to Value Based Care (VBC), a portion of Medicare reimbursements will continue to be tied to PSIs making accurate PSI reporting more crucial than ever. It bears mentioning that public PSI data can also harm a hospital's reputation, leading to reduced patient volume and further revenue loss. To reduce revenue leakage caused by inaccurate PSI reporting, healthcare systems must focus on improving the accuracy of their documentation and coding. Many reported PSIs can be avoided if accurately documented, especially by drawing on the knowledge of Clinical Documentation Integrity (CDI) and Quality experts. For example, establishing accurate present on admission (POA) status through simple queries can remove patients from specific PSI categories. In addition, understanding the specific exclusion diagnoses for PSIs, like those related to elective surgeries, can prevent inaccurate PSI reporting. Want to learn more about Patient Safety Indicators? Read our lates article on PSIs to learn more: Patient Safety Indicators: Aligning CDI and Coding with Quality Goals

1. The Expiration of ACA Subsidies Enhanced subsidies under the Affordable Care Act (ACA) are set to expire at the end of 2025. If Congress does not extend these subsidies, premiums for many enrollees could surge by more than 75%, leading to a significant rise in uninsured patients. For healthcare organizations, this could mean a decrease in commercially insured patients and an increase in Medicaid or uninsured populations, driving up uncompensated care and bad debt . Steps to Prepare: Identify Revenue Impact: Conduct financial modeling to assess the potential impact of payer mix shifts on your revenue. Optimize Medicaid Processes: Strengthen Medicaid eligibility and enrollment workflows to reduce gaps in reimbursement. Enhance Financial Counseling: Train staff to assist patients in exploring available insurance options and payment plans. By proactively addressing these areas, organizations can minimize revenue leakage and maintain financial stability. 2. Potential Changes to Medicare’s Inpatient Only List Efforts to phase out Medicare’s Inpatient Only (IPO) list have been a contentious topic. While earlier attempts to eliminate the list were reversed, a renewed focus on reducing covered inpatient procedures is possible. Hospitals may face increased pressure to justify inpatient admissions to ensure proper reimbursement. Steps to Prepare: Review Care Protocols: Ensure inpatient admissions align with Medicare guidelines by conducting regular audits. Strengthen Documentation: Partner with CDI experts to bolster clinical documentation supporting medical necessity. Develop Training Programs: Educate care teams on evolving regulations and documentation best practices. These measures will help organizations navigate the transition while securing appropriate reimbursements. 3. Medicare Advantage Expansion The growth of Medicare Advantage plans continues to raise concerns for providers. These plans often deny claims at twice the rate of commercial insurance , adding administrative burdens that strain resources. Any expansion of these plans could significantly affect hospital cash flow and operational efficiency. Steps to Prepare: Conduct a Denials Assessment: Identify root causes of denials and implement corrective action plans. Automate Claims Processes: Leverage technology to streamline workflows and improve claims accuracy. Partner with Experts: Collaborate with a third-party partner like UASI to manage denials efficiently and reduce administrative strain. By taking these steps, healthcare organizations can mitigate the impact of Medicare Advantage expansion on revenue cycles. 4. The Rise of Site-Neutral Payment Policies Site-neutral payment policies—requiring Medicare to reimburse services equally across care settings—pose another potential challenge. While aimed at cost savings, these policies often overlook the higher operating costs of hospitals, which provide 24/7 care and meet rigorous regulatory requirements. A mid-sized health system, for example, could lose upwards of $5 million annually under expanded site-neutral rules. Steps to Prepare: Analyze Service Lines: Evaluate which services are most vulnerable to site-neutral payment changes and adjust strategies accordingly. Advocate for Fair Reimbursement: Join industry groups to advocate for policies that reflect the higher costs of hospital-based care. Diversify Revenue Streams: Explore alternative revenue opportunities, such as outpatient services and partnerships. Preparing for these changes will position providers to adapt to regulatory shifts and safeguard financial health. Leveraging Industry Insights for Better Outcomes Industry trends highlight the critical importance of reducing revenue leakage through proactive strategies. These include improving documentation accuracy, conducting denial program assessments, and leveraging innovative technologies like AI. By aligning your organization with these approaches, you can address common challenges such as rising denial rates, compliance risks, and inefficiencies in revenue cycle management. UASI’s expertise supports these priorities by helping providers strengthen their financial and operational performance. Whether it’s addressing the impact of payer mix changes, improving claims accuracy, or mitigating regulatory risks, our tailored solutions empower organizations to navigate an increasingly complex healthcare environment. UASI remains a trusted partner through change and uncertainty, offering the expertise and support needed to navigate these challenges while driving financial and operational success for healthcare organizations. References: ACA Subsidies Impact: https://www.kff.org/interactive/how-much-more-would-people-pay-in-premiums-if-the-acas-enhanced-subsidies-expired/ Medicare Inpatient Only List Updates: https://www.findacode.com/newsletters/aha-coding-clinic/hcpcs/cy2024-changes-medicares-inpatient-list-H241004.html Medicare Advantage Expansion Concerns: https://jamanetwork.com/journals/jama-health-forum/fullarticle/2815743 Site-Neutral Payment Policy Analysis: https://www.aha.org/fact-sheets/2023-03-21-fact-sheet-medicare-hospital-outpatient-site-neutral-payment-policies

“Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence” On December 4, 2024 , Title 42 of the Medicare Advantage plan was amended by CMS and the goal was to implement reforms that will ultimately improve healthcare access, quality, and equity for Medicare beneficiaries . This change is related to executive order 14110 by the Biden-Harris Administration, “Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence” which ensures that the development of AI does not jeopardize the advancement of equity and civil rights especially in health organizations. Institutions that do not comply with this amendment will be subjected to possible prosecution. Artificial Intelligence (AI) is rapidly becoming a prominent force in our society, and its application in healthcare is viewed with both hope and caution . Health information professionals must understand what AI entails, its capabilities, and how to employ it responsibly and ethically. With increased use of AI in healthcare, questions arise about maintaining patient trust and safeguarding data integrity , especially given the discrepancies and accuracy rate of AI-driven data collection and analysis. Additionally, with the increasing automation of revenue cycle operations in healthcare systems, ensuring coding accuracy, billing, and documentation in this evolving landscape becomes even more crucial . AHIMA and GDHP Partner for First Health Information Summit In November AHIMA and IFHIMA joined forces and conducted the first global policy summit of health information professionals and presented on public issues related to the health information profession in collaboration with GDHP (Global Digital Health Partnership), a collection of national digital health authorities and the World Health Organization (WHO). In short, digital health is the “systematic application of information and communications technologies, computer science, and data to support informed decision-making by individuals, the health workforce, and health institutions, for strengthened resilience and improved health and wellness for all.” Digital health includes digital technology-based data fields e.g., data analytics, artificial intelligence, eHealth, and telemedicine, to name a few. A central concern of the summit was the evolving impact of digital health technologies, in particular the implementation of AI, and the priorities and needs of professionals within the health information sector as they relate to digital health. During the summit, key policies were discussed that are currently impacting the health information profession. UASAID Recommended Practices  In addition to the global policy health summit, the United States Agency for International Development (USAID) recently released a position paper titled Digital Health which outlined four priorities for programmatic digital health investments . These focal areas underscore the federal government’s strategic emphasis on advancing digital health technologies . These priorities range from strengthening a country’s digital health environment to aligning digital health investments with national architecture. Additional recommended practices outlined by USAID include: · Requiring standards to enable integrated health care service delivery at scale . · Establishing standards that equate to better coordination of care , and deepening engagement with local partners . · Engaging with local partners including the private sector to support the ability of global health funders like USAID to be effective long-term partners to government ministries of health. Preparing for AI Advancement in the Mid Revenue Cycle CFO’s and Directors of HIM need to ensure compliance with CMS regulations while preparing for stricter federal-level oversight in addition to monitoring the overall performance of AI solutions. The need for education and training will continue to grow to accurately assess AI-driven data, ensuring that decision-making remains informed and aligned with regulatory standards. UASI collaborates with healthcare systems to enhance workforce capabilities in exchanging and using relevant healthcare data by reviewing and identify coding and documentation errors that impact revenue integrity and patient care , ensuring the accuracy and integrity of patient information. UASI is committed to supporting the digital transformation of health systems with long-term vision of achieving data interoperability , ensuring equity in the use of AI , and creating globally sustainable health systems .

Value-based care (VBC) models are continuing to gain traction to improve care outcomes while controlling costs. However, the transition to VBC comes with its own set of challenges, specifically around risk adjustment, which is vital to ensuring accurate reimbursement. To better understand these hurdles, UASI asked industry leaders for their insights into the complexities of implementing and managing Risk Adjustment in VBC models. Key Challenges in Adopting VBC Models Industry leaders in healthcare highlighted several challenges related to adopting Value-Based Care models and identified several barriers; Staff resistance to new care delivery and reimbursement models, and a lack of education and training hinders understanding and adoption of VBC. Aligning processes and workflows with new care models can disrupt established practices, while difficulties in aligning with payor contracts, due to varying quality metrics and reimbursement formulas, create further obstacles. Additionally, many healthcare systems face inadequate operational capacity and a shortage of a specialized workforce , making it difficult to scale VBC models effectively. Resources for VBC Implementation and Optimization To effectively manage value-based care (VBC) models , industry leaders weighed in and identified several key resources to better support VBC implementation. Those organizations with more mature programs have 6 key components in place in managing a successful program: The main needs identified were data analytics to track patient outcomes and costs Comprehensive training and education programs to equip staff with the knowledge to effectively implement VBC. Leaders in Risk Adjustment would like to see a defined strategy and objectives within their organizations to guide decision-making The tools and technology to support the strategy. Financial incentives from payors are needed such as quality measures and shared savings programs to leverage more support for VBC implementation. Regulatory guidance can also help health systems to navigate VBC complexities and ensure compliance. Challenges in Data Accuracy and Metrics for Evaluating Success Data accessibility and accuracy are major barriers within Risk Adjustment. Ensuring that data is comprehensive and accurate is needed for calculating risk scores and understanding where to focus efforts. With multiple risk adjustment models in place, organizations struggle to find processes that create efficiencies. Additionally, provider burnout and workflow management issues arise as providers navigate various VBC models. To ensure effectiveness, there are a set of metrics to evaluate Risk adjustment and value-based care models: Hospital Readmission Rates : Reducing hospital readmissions indicates the success of preventive care and is a goal of VBC. · Mortality Rates : Mortality rates focus on the overall quality of care and patient outcomes. Cost per Patient per Month (PMPM) and Total Cost of Care : Tracking the cost per patient is essential to managing the financial aspects of VBC, ensuring that the system remains financially viable while improving care quality. Total cost of care is a broad metric that captures the financial efficiency of the care model. Shared Savings Revenue : This metric tracks the financial savings generated through VBC initiatives, which are shared between providers and payors. Quality Scores (HEDIS, STAR Ratings) : National quality measures such as HEDIS and STAR ratings provide objective benchmarks for evaluating the effectiveness of care delivery. Risk Adjustment Accuracy Scores (RAF, Recapture Rate) : These scores are essential for evaluating the precision of risk adjustment models. RAF is the estimated yearly cost to treat a patient whereas the Recapture Rate refers to how well a provider captures recurring HCC diagnoses and is also used to understand future healthcare costs. Suggestions for Improvement Improvements must be organizational and system wide as industry leaders highlight that viewing Risk Adjustment and VBC as just a revenue cycle or coding issues is a major barrier. Instead, these challenges require an integrated approach involving clinicians, administrators, and payors to drive the necessary changes . As previously stated, healthcare organizations face challenges like staff resistance, workflow management, and data accessibility/accuracy. However, with the right resources these obstacles can be overcome. Let UASI help you bridge the gap by assessing your Risk Adjustment practices, identify gaps, and develop targeted solutions.

In 2021, the New Technology Add-on Payment (NTAP) program was created by The Center for Medicare & Medicaid Services (CMS) to increase the use of new inpatient technologies in the Medicare population. CMS uses NTAP codes for qualifying products that promise improvement in process or outcomes. Additionally, these new medical services and technologies are eligible for an add-on payment known as NTAP which presents significant reimbursement opportunity for hospitals and healthcare systems that adopt these technologies. Eligibility Criteria for NTAP Payments To be eligible for the NTAP, these technologies must meet the following 3 criteria. When the following criteria are met, the NTAP payments are significantly greater than the standard Medicare Severity Diagnosis-Related Group (MS-DRG). 1.) Technology must be new within 2-3 years of market introduction. 2.) The technology must “substantially improve the diagnosis or treatment relative to currently available technologies and are inadequately paid otherwise under the current diagnosis-related group (DRG) reimbursement rates.”1 3.) The technology is deemed inadequately compensated under the current MS-DRG, as its average standardized charge for inpatient cases exceeds the set cost threshold. FY 2025 Program Expansion: 39 New Technologies Approved The number of approved technologies has increased each year since its inception. The FY 2025-year list is the most extensive since the program began and includes 39 Total NTAPs. • CMS finalized the continuation of new technology add-on payments for 24 existing new technologies • CMS finalized discontinuing new technology add-on payments for 7 current new technologies • CMS finalized 16 of the original 27 new technologies submitted for new technology add-on payments under the traditional and alternative pathways Financial Impact: What NTAP Can Mean for Your Hospital’s Reimbursement According to CMS, new technology add-on payments are limited to the lesser of 65% of the costs of the technology, or 65% of the amount by which the costs of the case exceed the standard MS–DRG payment”. The most substantial financial impact approved for FY 2025 Casegevy and Lyfgenia. Both are medications for gene therapies that treat sickle cell disease. These medications qualify for 75% NTAP amount resulting in a maximum payment of $1.65 Million for Casgevy and $2.32 Million for Lyfgenia. Key Steps to Maximize NTAP Reimbursement For hospitals and health systems, it is essential to take the following steps to ensure full NTAP reimbursement: Accurate Coding: Make sure the correct ICD-10-PCS code(s) are included on claims to qualify for NTAP payments. Missing or inaccurate codes can lead to lost revenue. Annual Review of NTAP Services: Each year, inpatient coding staff should review the latest list of approved NTAP services and technologies to stay updated on new opportunities for reimbursement. Routine Audits: Conduct regular internal and external audits to confirm that all eligible procedures and technologies are correctly coded and reimbursed. These audits help identify and prevent potential revenue leakage. Taking these proactive measures can help ensure your hospital captures all eligible NTAP reimbursements. Not Sure if You’re Capturing All Possible NTAP Revenue? Contact UASI for a comprehensive NTAP assessment. Our expert audit team is ready to help your hospital secure eligible NTAP payments and maximize revenue potential. Do not let money slip through the cracks - Reach Out Today! References 1. Adoption and Trends in the Medicare New Technology Add-On Payment Program - PubMed Central (PMC) 2. New Medical Services and New Technologies - Centers for Medicare & Medicaid Services (CMS)

In today’s complex healthcare environment, optimizing the revenue cycle is more crucial than ever. As healthcare systems face increasing financial pressures, effective revenue cycle management (RCM) is essential for maintaining both operational efficiency and financial health. Leslie Vairo, Senior Consulting Director in Revenue Cycle at Vizient, is at the forefront of helping health systems navigate these challenges. With her broad experience in healthcare and finance, Leslie's expertise is key to helping enhance hospital operations and maximize revenue streams. As a leading healthcare performance improvement organization, Vizient partners with more than half of US healthcare organizations. The organization provides end-to-end assessments that help organizations improve performance, increase revenue, and optimize their operations. By working closely with health system leadership, Vizient conducts assessments of the revenue cycle process, that include denials management to coding accuracy, identifying areas where there is revenue leakage. The goal is to develop long-term strategies for sustainable improvement.  3 Common Revenue Cycle Challenges During assessments, Leslie noted that Vizient often encounters recurring issues that contribute to lost revenue Denials Management: Often, hospitals struggle with authorization errors, inaccurate coding, and unresolved payment issues, all of which can delay or prevent reimbursement. These issues are exacerbated by outdated systems and a lack of standardized processes across different payers, especially with Medicare and other insurers that have different billing guidelines. Aging Coding Staff & Coding Accuracy: The healthcare industry faces a growing shortage of qualified medical coders, which has led to an aging coding workforce. In addition, Leslie noted that coding accuracy is a major issue, with some facilities reporting accuracy rates below 90%. Hospitals often don’t realize how much this shortfall costs them in lost revenue. The financial strain is also compounded by the backlogs of charts that is a direct result of the medical coding staff shortage. Revenue Leakage: Underpayments or overpayments are another key issue that delays revenue flow. Often referred to as revenue leakage, these discrepancies result from inefficient claims processing or errors in billing, leading to delayed or lost payments. Leslie’s assessments reveal that many hospitals have significant opportunities to recoup revenue by improving accuracy in their coding and billing procedures. People, Process & Partnerships Hospitals are often eager to invest in new technologies, but Leslie points out that technology alone is not enough. Many hospitals purchase systems like EPIC or are now considering AI, hoping the technology will automatically improve their revenue cycle performance. However, without addressing the people and processes that drive the technology, the return on investment (ROI) is often limited. Hospitals must focus on aligning technology with the necessary skill development and change management to maximize its effectiveness. One of the barriers Leslie encounters is the resistance to change from hospital staff, particularly when it comes to legacy teams that have not looked at or updated their program’s operations. These barriers can be especially pronounced when hospitals are presented with data analysis that shows they are leaving millions of dollars on the table due to inefficiencies in their revenue cycle. Overcoming this resistance requires not only clear communication in these assessments but also demonstrating the tangible financial benefits that can result from program optimization. As hospitals strive to address these challenges, especially in the face of staffing shortages, it becomes necessary to partner with external vendors to fill critical roles in the revenue cycle. Leslie says that partners like UASI can bring much-needed specialized resources to help streamline the revenue cycle and stay up to date in a dynamic environment. These partnerships also enable hospitals to access skilled professionals who can address coding and billing challenges while maintaining compliance. Advice for New Rev Cycle Leaders For new leaders stepping into revenue cycle roles, Leslie offers several key pieces of advice to help set them up for success: 1. Review Historical Data : Look back at accounts receivable (AR) and collections trends to establish a benchmark. Most hospitals focus on current performance without comparing it to historical data, which makes it harder to identify trends and areas for improvement. 2. Build Strong Relationships : Work closely with hospital executives and make sure that everyone understands the importance of the revenue cycle. As Leslie points out, the revenue cycle is an integral part of a hospital’s financial health and getting buy-in from leadership is essential for driving change. The Path Forward for Health Systems Revenue cycle management is more than just a financial function, it is a critical component of operational success and therefore, impacts patient care. By addressing issues like coding accuracy, denials management, and staffing shortages, hospitals can unlock significant revenue opportunities and improve their overall financial health. Hospitals that take a comprehensive approach to their revenue cycle will be better positioned to deliver high-quality care while maintaining financial sustainability. Reach out today to learn how a UASI & Vizient partnership can help impact quality outcomes and improve organizational sustainability. Contact Us Today!

Transient Tachypnea of the Newborn (TTN) TTN : a parenchymal lung disorder characterized by pulmonary edema resulting from delayed resorption and clearance of fetal alveolar fluid. It is the most common cause of respiratory distress in late preterm and term infants and is generally a benign, self-limited condition. Clinical Manifestations of TTN · Onset usually between the time of birth and two hours after delivery · Tachypnea – most common feature with respiratory rate > 60 breaths per minute · Infants with more severe disease may exhibit: Cyanosis Increased work of breathing which includes: Nasal flaring Mild intercostal and subcostal retractions Expiratory grunting · Anterior-posterior diameter of the chest may be increased · Typically with clear lungs (no rales/rhonchi) · Mild to moderate TTN are symptomatic for 12-24 hours but signs may persist as long as 72 hours in more severe cases · Characteristic radiographic features: o CXR – increased lung volumes with flat diaphragms, mild cardiomegaly, prominent vascular markings in a sunburst pattern originating at the hilum, fluid in the interlobar fissures, pleural effusions, alveolar edema appearing as fluffy densities. There are no areas of alveolar densities or consolidation o Lung US – pulmonary edema, compact B lines, double lung point, regular pleural line without consolidation TTN is a benign disorder and pathologic conditions that also present with respiratory distress must be excluded. Pneumonia – chest radiography differentiates PNA from TTN as neonatal PNA is characterized by alveolar densities with air bronchograms or patchy infiltrates, not seen in TTN. Sepsis – infants with sepsis and respiratory distress are differentiated from those with TTN with the persistence of additional symptoms and the lack of the characteristic chest radiographic findings of TTN. Congenital cardiac disease - TTN is distinguished from congenital heart disease by physical findings (e.g., heart murmur, abnormal precordial activity), chest radiography, pre- and post-ductal pulse oximetry, and echocardiography. Respiratory distress syndrome – differentiated from TTN with a characteristic chest radiograph of a ground glass appearance with air bronchograms. Caused by surfactant deficiency most common in very preterm infants. Code for Transient tachypnea of newborn (TTN) falls under ICD-10 Chapter 16 – Certain conditions originating in the perinatal period [P00-P96] · P19-P29 – Respiratory and cardiovascular disorders specific to the perinatal period · P22 - Respiratory distress of newborn · P22.0 – Respiratory distress syndrome of newborn · P22.1 – Transient tachypnea of newborn · P22.8 – Other respiratory distress of newborn · P22.9 – Respiratory distress of newborn, unspecified Additional Tips: · TTN is also documented as Respiratory distress syndrome Type II, Wet lung syndrome · Tachypnea alone is just a symptom · Most common risk factors for TTN include prematurity, Cesarean delivery, maternal diabetes, maternal obesity, maternal asthma · Infants with TTN rarely require a fraction of inspired oxygen (FiO2) >0.4. References Johnson, K. E. (2021, August 30). Transient tachypnea of the newborn. UpToDate. www.uptodate.com/contents/transient-tachypnea-of-the-newborn “Respiratory Conditions Neonatal.” Pro ACDIS Pocket Resource Online, pro.acdis.org/inpatient/conditions/respiratory-conditions-neonatal. Accessed 4 Dec. 2023.

Can Providers Truly Win?

Cincinnati, OH — UASI is excited to announce the addition of Rachel Mack, MSN, RN, CCDS, CDIP, CCS, CRC, to the team as Managing Consultant in Clinical Documentation Integrity (CDI). Rachel brings over 15 years of experience in CDI and healthcare management, with a well-rounded background as a CDI Specialist, Educator, and Auditor. Her expertise in inpatient hospital CDI/coding, CDI technology, risk adjustment methodologies, and Medicare will significantly enhance UASI's commitment to delivering exceptional documentation solutions. Rachel has demonstrated her dedication to advancing CDI through her strong leadership in program and project management, with a Master's degree in Nursing Administration from Jacksonville University. She has worked closely with physicians to implement effective CDI strategies and has a proven track record in PSI prevention and Medicare compliance. “I am passionate about all things CDI and am thrilled to bring my experience to UASI,” said Rachel Mack. “I look forward to working with a team that shares my commitment to enhancing healthcare outcomes through innovative CDI practices.” Rachel's industry influence extends beyond her work with hospitals. She has been a sought-after speaker at major industry conferences, including her recent presentation on Social Determinants of Health (SDoH) at the 2023 ACDIS Conference alongside Connie Ryan. She also organized and presented at Vizient’s webinar series in 2021, 2022, and 2023, covering topics like CDI and Cardiac Surgery, Sepsis, Respiratory Failure, Risk Adjustment, and PSIs/HACs. Rachel's expertise and thought leadership were also featured at several ACDIS Conferences. About UASI For over four decades, UASI Solutions has led the healthcare industry in revenue cycle management, providing tailored solutions to optimize fiscal performance and drive sustainable growth. Established in 1984, our commitment to innovation and client success has solidified our position as trusted partners nationwide. With a comprehensive suite of services, including Remote Coding, Clinical Documentation Improvement, and Revenue Integrity, we remain dedicated to delivering value and driving results for our clients every step of the way. For more information, please visit www.uasisolutions.com .

Healthcare is evolving, and as we move forward with quality care and compassion, it’s crucial to address the factors that significantly impact patient outcomes beyond traditional medical care. Social determinants of health (SDoH) are these non-medical factors—such as access to food, stable housing, transportation, and utility services—that influence a person's overall health and treatment outcomes. By effectively addressing and coding these determinants, providers can enhance care while also accessing additional reimbursement opportunities. CMS Strategic Plan “The Centers for Medicare & Medicaid Services (CMS) infuses health equity in everything it does. CMS is working to advance health equity so that each person has a fair and just opportunity to attain their highest level of health regardless of their age, race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.” CMS wants to make sure that all individuals and families have access to quality healthcare. To do this CMS has to remove the barriers to healthcare and support and partner with providers to ensure that every person and family can access care they need. Starting in January 2024, CMS began offering coverage for HCPCS code G0136. This coverage allows providers to be reimbursed when they use a standardized, evidence-based SDoH risk assessment tool that evaluates crucial areas such as food insecurity, housing instability, transportation needs, and utility difficulties. To comply with G0136, providers must use validated tools that have been independently tested. The 2024 MPFS final rule specifies some approved tools, including: CMS Accountable Health Communities Tool Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE) Medicare Advantage Special Needs Population Health Risk Assessment The key is to find a tool suitable for your practice’s patient population while ensuring it meets CMS requirements. Documentation of the tool used in the patient record is also critical. Hospital Outpatient Quality Reporting Program (OQR) CMS is expanding its focus on SDoH beyond inpatient settings. The Hospital Outpatient Quality Reporting Program (OQR), a pay-for-reporting quality program, requires hospital outpatient departments to meet specific quality reporting requirements. Failure to do so results in a 2% reduction in their annual payment update. CMS is proposing to adopt the screening of Social Drivers of Health measure, with voluntary reporting starting in CY 2025, followed by mandatory reporting beginning in CY 2026. This expansion reflects CMS’s recognition of the importance of social factors in shaping health outcomes. It provides healthcare providers with the tools to identify at-risk populations and develop targeted interventions. The Commitment to Health Equity measure further encourages healthcare organizations to integrate equity into their strategic and operational goals, fostering a culture of accountability and continuous improvement. Expanded Reimbursement Opportunities CMS is committed to advancing health equity and has included measures to support providers and hospitals in addressing social drivers of health. For example, the new policy finalized for FY 2024 recognizes the higher costs that hospitals face when treating patients experiencing homelessness or housing insecurity. This policy introduces new codes effective from October 1, 2024, which will be classified as complications or comorbidities (CCs), thus increasing reimbursement for specific diagnosis-related groups (DRGs). These codes include: Z59.10 (Inadequate housing, unspecified) Z59.11 (Inadequate housing, environmental temperature) Z59.12 (Inadequate housing, utilities) Z59.19 (Other inadequate housing) Z59.811 (Housing instability, housed with risk of homelessness) Z59.812 (Housing instability, housed, homelessness in past 12 months) Z59.819 (Housing instability, housed, unspecified) Real-World Scenarios: How SDoH Coding Can Make a Difference Here are some examples where documenting SDoH impacts patient care and enhances reimbursement: A patient is diagnosed with hypothermia, and the physician documents that their home does not have heating. Code: Z59.11 (Lack of heating). A child’s record shows a history of food insecurity due to financial difficulties at home, leading to hunger. Code: Z59.48 (Lack of food). A patient misses multiple appointments due to transportation issues. Code: Z59.82 (Lack of transportation). A patient becomes homeless following the foreclosure of their home. Code: Z59.819 (Housing instability). Why This Matters for Your Practice Incorporating SDoH documentation not only improves patient care but also opens up significant reimbursement opportunities. UASI is here to guide you through these changes and help your practice implement these assessments seamlessly. Our expertise ensures your compliance with the latest CMS guidelines, helping you maximize reimbursement potential while enhancing patient outcomes.  Take Action Today Don’t let your practice fall behind in leveraging these opportunities. Contact UASI to learn how our clinical documentation and coding solutions can empower your practice to succeed. Together, we’ll build a more equitable, efficient, and effective healthcare environment for your patients.

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

Taxpayers spend an average of $2.5 trillion overall for healthcare in the United States as the healthcare industry continues to face complex challenges in the coming year. While this is happening, providers feel the growing financial burden as tensions continue to rise between payers and providers. Understanding the current landscape will allow organizations, providers, and payers to proactively prepare their internal processes to meet industry needs and standards. As a reference point, in January 2024, national health spending grew by 6.0% since January 2023 and represented 17.4% of GDP. Nominal GDP in January 2024 was 5.1% higher than in January 2023, growing more than 0.8 percentage points more slowly than health spending. The Health Research Institute (HRI) of Price Waterhouse Cooper recently predicted 2025 to have the highest medical cost trend in 13 years. HRI asserts that this trend is “driven by inflationary pressure, prescription drug spending and behavioral health utilization”. Even with the rising cost of healthcare, there is a decrease in overall revenue. What CFOs should be aware of is that this financial pressure will affect cash flow, reimbursement rates, and the ability to maintain margins. Each day, we’ll be highlighting a critical area that mid-revenue cycle leaders should prioritize to prepare for these market shifts and reduce revenue leakage in 2025. The 5 areas we’ll cover include: #1 SDoH and Reimbursement Impact #2 Tackling the Growing Threat of Claim Denials #3 Avoid Costly Recoupments & Identify Missed Reimbursement Opportunities #4 Harnessing Artificial Intelligence #5 Reduce Penalties Through Accurate PSI Reporting #1 Social Determinants of Health (SDoH) & Reimbursement Impact The current focus on Social Determinants of Health (SDoH) will continue into 2025. The Inpatient Prospective Payment System (IPPS) final rule provided some good news related to SDoH. CMS plans to increase the federal standard rate by 2.9%. Part of this increase is a change in severity assignment for some SDoH codes. Specifically, treatment plans or encounters related to inadequate housing or housing instability will become a CC (Comorbidity Code) in 2025. The rationale for the changes in severity is due to the anticipated higher than average resource costs associated with these patients. According to the U.S. Department of Health and Human Services, “In the FY 2024 IPPS final rule, CMS finalized a policy change to recognize the higher costs that hospitals incur when they provide hospital services for individuals experiencing homelessness. Building on this policy and the Biden-Harris Administration’s initiative to address unsheltered homelessness, CMS is taking an additional step to better account for the resources involved in furnishing care to individuals experiencing housing insecurity, meaning that hospitals will generally receive higher payments when a patient is experiencing housing insecurity.” Healthcare leaders in the mid revenue cycle can reduce revenue leakage by focusing on accurate documentation and coding of SDoH. In particular, accurate documentation related to housing insecurity should be a critical focus as the 2025 IPPS changes will increase reimbursement rates for these patients. Accurate documentation of SDoH codes will not only improve reimbursement but also help address the higher resource costs associated with treating this patient population. Read our recent article on SDoH to learn more! SDoH Can Make a Big Difference in Patient Care and Reimbursement #2 Tackling the Growing Threat of Claim Denials As we move into 2025, claim denials are expected to remain a significant challenge for healthcare providers and organizations. Denied claims disrupt cash flow, create additional administrative burdens, and can even impact the quality of patient care. According to a recent survey by Experian Health, 38% of healthcare professionals reported that one in every ten claims is denied, while 73% noted that denials rates are on the rise. This increase of denials is putting additional strain on already overburdened healthcare systems and making it harder for providers to maintain operational efficiency. Most healthcare systems are struggling to address the growing volume of claim denials, and because of the administrative burden, fixing the root cause is often overlooked. With increasing claim volumes and complex payer requirements, healthcare providers are overwhelmed by the sheer number of denials in addition to the need to meet multiple deadlines for denials appeals. Compounding this challenge is the lack of specialized expertise in handling claim denials, which makes organizing the workflow and managing the appeals process difficult. Healthcare organizations that fail to address their claim denials are left vulnerable to revenue leakage through missed opportunities for reimbursement. Conducting a denials program assessment is a necessary first step in understanding the root causes of denials and identifying areas for improvement. An assessment can help organizations gain insight into denials trends, develop targeted strategies to reduce denials, and identify ways to implement more efficient workflows. Additionally, an assessment can help identify where education and training are needed to improve accuracy and prevent denials altogether. Many systems find it difficult to even address all the denials as they come in, so they find it challenging to conduct an assessment. Partnering with a third-party authority can help with capacity to get an assessment completed but also provide an objective perspective. In addition, an outsource partner and/or implementing A.I. can help alleviate the burden and cover more volume. An assessment can help identify the best options to solve the problem. #3 Avoid Costly Recoupments & Identify Missed Reimbursement Opportunities In 2024, the Office of Inspector General (OIG) identified several areas in healthcare billing that could cost the American taxpayers billions of dollars in recoupments. To note, the OIG conducts audits to ensure that healthcare claims are compliant with federal regulations. For example, one of the significant findings from the OIG in 2024 was noncompliance with the “two-midnight rule”, which requires a patient’s hospital stay to span two midnights to qualify for inpatient payment. In 2025, OIG audits are expected to continue focusing heavily on validating claims data, ensuring accurate code assignment, and confirming that clinical documentation supports medical necessity. Healthcare systems must prepare for increased scrutiny of their claim’s data. Without a process in place to identify discrepancies in documentation early on, healthcare providers risk triggering unnecessary OIG audits, which could result in costly recoupments. Often, third-party audits are conducted too late once discrepancies have already led to compliance issues and financial loss. This reactionary approach can be avoided by completing preemptive reviews and audits before an official OIG audit occurs. To stay ahead, healthcare organizations must shift their mindset from a reactive to a proactive approach. By conducting regular, ongoing audits or reviews, providers can identify risks and address pitfalls before they escalate into major compliance issues. Furthermore, healthcare systems who elect to conduct proactive 3rd party audits, should view them not merely as a tactic to avoid OIG audits, but as a larger, strategic move to boost ROI by ensuring accurate coding and reimbursement opportunities. Preliminary audits arm healthcare systems with the information and resources to comply with federal regulations while discovering opportunities for increased revenue. #4 Harnessing Artificial Intelligence In utilizing vast amounts of data, A.I. can be harnessed to increase productivity. With these advancements and their impact on the revenue cycle, it is leaving industry experts wondering how the function of accurate code assignment will look in the future. In addition, for smaller healthcare organizations with lower patient volumes, the adoption of A.I. may seem out of reach. This leaves many leaders in the mid revenue cycle uncertain about how to begin integrating these technologies into their operations. As the technology develops and improves, A.I. has the potential to reduce administrative burdens and address the complexity of billing and coding accuracy while improving patient care. These potential improvements could impact the financial health and sustainability of hospitals and physician groups nationwide. To combat healthcare’s rising costs, increase in payer denials, and the need for accurate code assignment, the integration of AI into the revenue cycle will likely become a key competitive differentiator for healthcare organizations in 2025. While the integration of A.I. in CC (Code Capture) has become more widespread, the technology often requires significant volume, so many smaller healthcare facilities have yet to benefit. In addition, the more complex aspects of coding still require human oversight and expertise. The challenge that many health systems face is in regard to identifying the right tool and how to begin integrating new tools into an already established workflow. Partnering with firms that can assist in evaluating AI tool options, help healthcare facilities manage the people processes, and develop the roadmap associated with these new technologies to ensure ROI, is worth consideration. Short term spend for long-term benefits. #5 Reduce Penalties Through Accurate PSI Reporting Patient Safety Indicators (PSIs) are a set of measurement tools developed by the Centers for Medicare and Medicaid Services (CMS) to track adverse patient outcomes, such as hospital-acquired infections, falls, and other complications. These indicators are used to assess the quality of care provided by hospitals and highlight areas where patient safety can improve. Hospitals are required to report PSIs to CMS as part of their participation in Medicare and Value-Based Care programs. PSIs directly impact revenue through penalties and reduced reimbursements. Hospitals with high rates of hospital-acquired conditions are penalized with lower reimbursements, particularly if they rank in the bottom 25% of PSI 90 scores. Despite improvements in PSI reporting, CMS consistently penalizes the lowest performing facilities. In addition, as the healthcare industry continues shifting to Value Based Care (VBC), a portion of Medicare reimbursements will continue to be tied to PSIs making accurate PSI reporting more crucial than ever. It bears mentioning that public PSI data can also harm a hospital's reputation, leading to reduced patient volume and further revenue loss. To reduce revenue leakage caused by inaccurate PSI reporting, healthcare systems must focus on improving the accuracy of their documentation and coding. Many reported PSIs can be avoided if accurately documented, especially by drawing on the knowledge of Clinical Documentation Integrity (CDI) and Quality experts. For example, establishing accurate present on admission (POA) status through simple queries can remove patients from specific PSI categories. In addition, understanding the specific exclusion diagnoses for PSIs, like those related to elective surgeries, can prevent inaccurate PSI reporting. Want to learn more about Patient Safety Indicators? Read our lates article on PSIs to learn more: Patient Safety Indicators: Aligning CDI and Coding with Quality Goals

Z Codes: Z00-Z99, Factors influencing health status and contact with health services This category of codes captures those circumstances that do not fall into disease, injury or external cause that classify into categories A00-Y89. Several Z codes will classify as a CC and represent circumstances that can impact medical decision-making, complexity, hospital resources, and length of stay. (e.g., antimicrobial resistance, SDOH, BMI, and transplant status) Let’s look at a few of these codes and dig into their clinical impact for patients and the providers managing their care. Individual codes were selected to demonstrate all the considerations of care for a single condition. The other codes would demonstrate a very similar picture. Click on the link to see the entire list of “Z” codes that classify as a CC at the end of this tip. Z16.12, Extended spectrum beta-lactamase (ESBL) resistance (Classifies as a CC) ESBLs are enzymes that destroy the beta-lactam ring in most beta-lactam antibiotics that include penicillins, cephalosporins, and the monobactam class antibiotic, aztreonam. They are associated with poor outcomes for patients with these infections. Confirmatory testing for the presence of ESBLs can be difficult as their structural makeup is not uniform. All ESBLs do not respond to the same antimicrobial agents. Rates for ESBL have increased from 11.1 infections per 100,000 patient days to 22.1 between 2009-2014. Rates in children have also increased from 0.28% in 1999-2001 to 0.92% in 2010-2011. Provider choice of antibiotics is crucial for clinical response and risk of mortality. A study shows that failure to treat appropriately in the first 5 days after culture result is associated with a 64% mortality rate versus 14% with an ESBL-sensitive choice. ESBL infections are associated with higher mortality rates, longer hospital stays, greater hospital expenses, and reduced rate of clinical response to treatment than similar gram-negative bacteria that do not produce ESBL. Z59.00, Homelessness, unspecified; Z59.01, Sheltered Homelessness; Z59.02, Unsheltered homelessness (All classify as CCs) Chronic homelessness is defined as, “an individual with a disabling condition who has been either continuously homeless for at least one year or homeless at least four times in the past three years” according to the US Department of Housing and Urban Development. Mortality rates among youth and young adults are 8-11-fold higher than the non-homeless population. Rates are also high for the unsheltered homeless population. Those experiencing homelessness have high rates of hospitalization and ER use compounded by poor access to primary care and many basic health services. There are several specific health conditions for the homeless population. These include skin and foot problems, respiratory infections, and issues with dentition. Conditions that are more comparable with the general population are often more poorly controlled. Patients that are experiencing homelessness present unique health risks and social challenges. Discharge planning can be a hurdle and hospital social service staff are critical. Z94.81, Bone marrow transplant status (Classifies as a CC) A procedure in which defective or cancerous bone marrow is replaced with healthy, new bone marrow cells. This helps with treatment of leukemia, lymphoma, sickle cell anemia, and multiple sclerosis. They may be autologous or allogenic. Patients are subject to numerous complications such as multi-organ effects, bleeding risk, mucositis, liver dysfunction, infections, and neuropsychiatric conditions. Those patients that are admitted to the ICU have higher rates of associated mortality. Development of any of these conditions may influence the quality of life, duration of hospitalization, longer-term complications, and outcomes from transplantation. Summary Although “Z” codes may not get the attention that other codes may get in the inpatient setting, they are important to capture the entire clinical picture for certain patient populations. The examples used in this tip are all codes that risk adjust in certain methodologies as well.  References Baggett, T. (2023). Healthcare of people experiencing homelessness in the United States. UpToDate. Retrieved on December 31, 2024 from https://www.uptodate.com/contents/health-care-of-people-experiencing-homelessness-in-the-united-states?search=homelessness&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1 Hooper, D. (2024). Extended-spectrum beta-lactamases. UpToDate. Retrieved on December 31, 2024 from https://www.uptodate.com/contents/extended-spectrum-beta-lactamases?search=antimicrobial%20resistance&source=search_result&selectedTitle=7%7E150&usage_type=default&display_rank=7 MD Anderson Cancer Center. (2025). Stem Cell (Bone Marrow) Transplants. mdanderson.org . Negrin, R. (2024). Early Complications of hematopoietic cell transplantation. UpToDate. Retrieved on January 14, 2025 from https://www.uptodate.com/contents/early-complications-of-hematopoietic-cell-transplantation?search=bone%20marrow%20transplant%20complications&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1 Pinson, R., Tang, C. (2024). The CDI Pocket Guide by Pinson and Tang. www.cdiplus.com .

1. The Expiration of ACA Subsidies Enhanced subsidies under the Affordable Care Act (ACA) are set to expire at the end of 2025. If Congress does not extend these subsidies, premiums for many enrollees could surge by more than 75%, leading to a significant rise in uninsured patients. For healthcare organizations, this could mean a decrease in commercially insured patients and an increase in Medicaid or uninsured populations, driving up uncompensated care and bad debt . Steps to Prepare: Identify Revenue Impact: Conduct financial modeling to assess the potential impact of payer mix shifts on your revenue. Optimize Medicaid Processes: Strengthen Medicaid eligibility and enrollment workflows to reduce gaps in reimbursement. Enhance Financial Counseling: Train staff to assist patients in exploring available insurance options and payment plans. By proactively addressing these areas, organizations can minimize revenue leakage and maintain financial stability. 2. Potential Changes to Medicare’s Inpatient Only List Efforts to phase out Medicare’s Inpatient Only (IPO) list have been a contentious topic. While earlier attempts to eliminate the list were reversed, a renewed focus on reducing covered inpatient procedures is possible. Hospitals may face increased pressure to justify inpatient admissions to ensure proper reimbursement. Steps to Prepare: Review Care Protocols: Ensure inpatient admissions align with Medicare guidelines by conducting regular audits. Strengthen Documentation: Partner with CDI experts to bolster clinical documentation supporting medical necessity. Develop Training Programs: Educate care teams on evolving regulations and documentation best practices. These measures will help organizations navigate the transition while securing appropriate reimbursements. 3. Medicare Advantage Expansion The growth of Medicare Advantage plans continues to raise concerns for providers. These plans often deny claims at twice the rate of commercial insurance , adding administrative burdens that strain resources. Any expansion of these plans could significantly affect hospital cash flow and operational efficiency. Steps to Prepare: Conduct a Denials Assessment: Identify root causes of denials and implement corrective action plans. Automate Claims Processes: Leverage technology to streamline workflows and improve claims accuracy. Partner with Experts: Collaborate with a third-party partner like UASI to manage denials efficiently and reduce administrative strain. By taking these steps, healthcare organizations can mitigate the impact of Medicare Advantage expansion on revenue cycles. 4. The Rise of Site-Neutral Payment Policies Site-neutral payment policies—requiring Medicare to reimburse services equally across care settings—pose another potential challenge. While aimed at cost savings, these policies often overlook the higher operating costs of hospitals, which provide 24/7 care and meet rigorous regulatory requirements. A mid-sized health system, for example, could lose upwards of $5 million annually under expanded site-neutral rules. Steps to Prepare: Analyze Service Lines: Evaluate which services are most vulnerable to site-neutral payment changes and adjust strategies accordingly. Advocate for Fair Reimbursement: Join industry groups to advocate for policies that reflect the higher costs of hospital-based care. Diversify Revenue Streams: Explore alternative revenue opportunities, such as outpatient services and partnerships. Preparing for these changes will position providers to adapt to regulatory shifts and safeguard financial health. Leveraging Industry Insights for Better Outcomes Industry trends highlight the critical importance of reducing revenue leakage through proactive strategies. These include improving documentation accuracy, conducting denial program assessments, and leveraging innovative technologies like AI. By aligning your organization with these approaches, you can address common challenges such as rising denial rates, compliance risks, and inefficiencies in revenue cycle management. UASI’s expertise supports these priorities by helping providers strengthen their financial and operational performance. Whether it’s addressing the impact of payer mix changes, improving claims accuracy, or mitigating regulatory risks, our tailored solutions empower organizations to navigate an increasingly complex healthcare environment. UASI remains a trusted partner through change and uncertainty, offering the expertise and support needed to navigate these challenges while driving financial and operational success for healthcare organizations. References: ACA Subsidies Impact: https://www.kff.org/interactive/how-much-more-would-people-pay-in-premiums-if-the-acas-enhanced-subsidies-expired/ Medicare Inpatient Only List Updates: https://www.findacode.com/newsletters/aha-coding-clinic/hcpcs/cy2024-changes-medicares-inpatient-list-H241004.html Medicare Advantage Expansion Concerns: https://jamanetwork.com/journals/jama-health-forum/fullarticle/2815743 Site-Neutral Payment Policy Analysis: https://www.aha.org/fact-sheets/2023-03-21-fact-sheet-medicare-hospital-outpatient-site-neutral-payment-policies

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?

Definition Pressure ulcers are localized damage to the skin and/or soft tissue caused by prolonged pressure, often associated with immobility and/or lack of sensation. Contributing factors can include moisture and nutritional deficiencies. Diagnostics Stages and Definitions (NPIAP; www.npiap.com ): Stage 2: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may present as an intact or ruptured serum-filled blister. Stage 3: Full-thickness skin loss. Adipose tissue is visible in the ulcer, with granulation tissue and epibole (rolled wound edges) often present. Slough and/or eschar may be visible. Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Slough and/or eschar may be present. Unstageable: Obscured full-thickness skin and tissue loss where the extent of tissue damage cannot be confirmed due to slough or eschar. Removal may reveal a Stage 3 or Stage 4 injury. Treatment Wound care/dressings, debridement, wound care referral, hyperbaric oxygen therapy Pain management, antibiotics, topical treatments Advanced stage treatment may include necrotic tissue excision, wet-to-dry saline or hypochlorite solution dressings, topical antibiotics, or specialized gels Background The term "pressure ulcer" is outdated. The National Pressure Ulcer Advisory Panel (NPIAP), founded in 1987, changed its terminology to "pressure injury" in 2016 and updated its name in 2019. A pressure injury is now defined as localized skin and soft tissue damage typically found over a bony prominence or caused by medical devices. Statistics on pressure injuries are limited. The 1999 Fifth National Pressure Prevalence Survey reported a 14.8% prevalence in acute care hospitals, with 7.1% occurring during hospital stays. Increased Risk Factors: Neurologic disease, cardiovascular disease, prolonged anesthesia, dehydration, malnutrition, hypotension, and surgery. ICD-10 Codes and HCC Mapping: HCC 379: Community, Non-Dual, Aged - 1.965 HCC 381: Community, Non-Dual, Aged - 1.075 HCC 382: Community, Non-Dual, Aged - 0.838 Coding and CDI Tips Document the pressure ulcer's location and its stage Note treatment and any complications related to the ulcer Indicate if there was a referral to wound care Clarify that pressure injuries are coded as pressure ulcers Differentiate pressure ulcers from moisture-associated skin damage (MASD) Specify ulcer stage, including unstageable ulcers, to ensure accurate HCC assignment For ulcers described as "healing," assign the code for the current stage. If "healed," no code is necessary Distinguish between pressure and chronic non-pressure ulcers , which map to different HCCs (380, 383) Query Example Visit note from [date] indicates the presence of a pressure ulcer on the right heel. The stage is not documented. Exam on [date] describes full-thickness ulceration into subcutaneous soft tissue. Please specify the stage of the pressure ulcer: Stage 2 Other stage (please specify)  References Centers for Medicare and Medicaid. (2023). Announcement of Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. CMS Edsberg, L. E., et al. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System. J Wound Ostomy Continence Nurs, 43(6), 585-597. doi:10.1097/won.0000000000000281 Tang, C., Pinson, R. (2024). CDI Pocket Guide by Pinson and Tang. CDI Plus Zaidi SRH, Sharma S. (2024). Pressure Ulcer. In StatPearls [Internet]. NCBI

“Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence” On December 4, 2024 , Title 42 of the Medicare Advantage plan was amended by CMS and the goal was to implement reforms that will ultimately improve healthcare access, quality, and equity for Medicare beneficiaries . This change is related to executive order 14110 by the Biden-Harris Administration, “Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence” which ensures that the development of AI does not jeopardize the advancement of equity and civil rights especially in health organizations. Institutions that do not comply with this amendment will be subjected to possible prosecution. Artificial Intelligence (AI) is rapidly becoming a prominent force in our society, and its application in healthcare is viewed with both hope and caution . Health information professionals must understand what AI entails, its capabilities, and how to employ it responsibly and ethically. With increased use of AI in healthcare, questions arise about maintaining patient trust and safeguarding data integrity , especially given the discrepancies and accuracy rate of AI-driven data collection and analysis. Additionally, with the increasing automation of revenue cycle operations in healthcare systems, ensuring coding accuracy, billing, and documentation in this evolving landscape becomes even more crucial . AHIMA and GDHP Partner for First Health Information Summit In November AHIMA and IFHIMA joined forces and conducted the first global policy summit of health information professionals and presented on public issues related to the health information profession in collaboration with GDHP (Global Digital Health Partnership), a collection of national digital health authorities and the World Health Organization (WHO). In short, digital health is the “systematic application of information and communications technologies, computer science, and data to support informed decision-making by individuals, the health workforce, and health institutions, for strengthened resilience and improved health and wellness for all.” Digital health includes digital technology-based data fields e.g., data analytics, artificial intelligence, eHealth, and telemedicine, to name a few. A central concern of the summit was the evolving impact of digital health technologies, in particular the implementation of AI, and the priorities and needs of professionals within the health information sector as they relate to digital health. During the summit, key policies were discussed that are currently impacting the health information profession. UASAID Recommended Practices  In addition to the global policy health summit, the United States Agency for International Development (USAID) recently released a position paper titled Digital Health which outlined four priorities for programmatic digital health investments . These focal areas underscore the federal government’s strategic emphasis on advancing digital health technologies . These priorities range from strengthening a country’s digital health environment to aligning digital health investments with national architecture. Additional recommended practices outlined by USAID include: · Requiring standards to enable integrated health care service delivery at scale . · Establishing standards that equate to better coordination of care , and deepening engagement with local partners . · Engaging with local partners including the private sector to support the ability of global health funders like USAID to be effective long-term partners to government ministries of health. Preparing for AI Advancement in the Mid Revenue Cycle CFO’s and Directors of HIM need to ensure compliance with CMS regulations while preparing for stricter federal-level oversight in addition to monitoring the overall performance of AI solutions. The need for education and training will continue to grow to accurately assess AI-driven data, ensuring that decision-making remains informed and aligned with regulatory standards. UASI collaborates with healthcare systems to enhance workforce capabilities in exchanging and using relevant healthcare data by reviewing and identify coding and documentation errors that impact revenue integrity and patient care , ensuring the accuracy and integrity of patient information. UASI is committed to supporting the digital transformation of health systems with long-term vision of achieving data interoperability , ensuring equity in the use of AI , and creating globally sustainable health systems .