UASI Welcomes Lora Council, RHIA, CDIP, CCS, as Client Success Manager UASI is pleased to announce that Lora Council, RHIA, CDIP, CCS has joined the team as Client Success Manager. Lora brings more than 16 years of experience in inpatient coding, auditing, and leadership, along with a strong record of improving quality and client outcomes. Before joining UASI, Lora served as DRG Assistant Manager at Machinify (formerly Varis, LLC), where she led a team of coders, managed performance across multiple health plans, and drove initiatives that improved coding accuracy and compliance. She also spent over a decade at LexiCode Corporation in leadership roles focused on coding quality, education, and client relations. Lora earned her Bachelor’s in Health Information Management from the University of Cincinnati and an Associate’s in Health Information Technology from Scott Community College. She holds AHIMA credentials as an RHIA, CCS, CDIP and a microcredential in Inpatient Coding Auditing. Lora is also an Adjunct Instructor in the Health Information Management Program at Eastern Iowa Community College, where she teaches ICD-10-PCS and Quality Management. “I am excited to join UASI and contribute to a company that values quality, collaboration, and client success,” said Lora Council. “My focus has always been on accuracy, education, and partnership, and I look forward to supporting UASI’s mission of excellence in healthcare auditing and documentation.” The addition of Lora Council reflects UASI’s continued commitment to strengthening its leadership team with experienced professionals who bring both technical expertise and a passion for client service. Her background in coding quality, education, and operations supports UASI’s mission to help healthcare organizations optimize performance, improve accuracy, and enhance patient care.

At the 2025 AHIMA Conference, Leah Jeffries, RHIT, CDIP, CCS, CCS-P, Managing Consultant at UASI, presented “The Nuances and Complexity of the Revenue Cycle Management of Critical Access Hospitals,” one of the most critical topics in rural healthcare. This session highlighted how Critical Access Hospitals (CAHs) sustain themselves in a complex regulatory and reimbursement environment and offered strategies for strengthening these lifelines of rural care. Setting the Stage: Why CAHs Matter Critical Access Hospitals are essential to improving healthcare access in underserved areas. Established under the Balanced Budget Act of 1997 to counter a wave of rural hospital closures, CAHs today provide inpatient, outpatient, swing-bed, and emergency services to communities that might otherwise face significant travel burdens or care gaps. They remain vital anchors for both healthcare delivery and local economies.

UASI Welcomes Amanda Brodsky as Client Success Manager – Coding Services UASI is thrilled to announce that Amanda Brodsky, CPC, COSC, has joined our team as Client Success Manager in Coding Services. In this role, Amanda will partner closely with our clients to oversee service deliverables, manage engagement scope, and ensure exceptional quality and performance across our coding solutions. She will also collaborate with our internal teams to drive continuous improvement, optimize coding outcomes, and uphold our commitment to excellence in client success. Amanda brings more than a decade of experience in medical coding, leadership, and team development. Before joining us, she served as a Coding Manager at Aquity Solutions, where she led multi-specialty coding teams, implemented productivity and quality initiatives, and maintained outstanding audit accuracy rates. Her proven leadership and dedication to client service make her a strong addition to our Coding Services team. Throughout her career, Amanda has advanced through several leadership and coding roles, building extensive experience across specialties such as Orthopedics, Pediatrics, and Pain Management. Amanda is a Certified Professional Coder (CPC) and Certified Orthopaedic Surgery Coder (COSC) through AAPC. She also holds a Coaching & Teambuilding for Managers and Supervisors certification from SkillPath and earned her Bachelor of Science in Political Science and Government from Northern Illinois University. “Amanda’s leadership experience and client-first mindset align perfectly with our mission to deliver high-quality, customized coding solutions,” said Donna Sherburne, Director of Coding Services. “We’re confident she will make an immediate and lasting impact for our clients and team members alike.” We’re excited to welcome Amanda to the UASI team and look forward to the expertise and energy she brings to our organization.

UASI is proud to announce the appointment of Angelica Cage, MBA, BSN, RN, CCDS, CCS, CDIP, CRCR, LSSGB, as Director of Denials & Strategy. With a background in critical care nursing, an MBA, and more than a decade of leadership in clinical documentation integrity, coding, denials management, and revenue cycle optimization, Angelica brings a rare blend of clinical expertise and strategic business acumen to the role. Angelica has successfully led teams and delivered large-scale solutions for some of the nation’s most respected health systems, including Tufts Medicine, and AdventHealth. She has driven significant CDI program enhancements, boosting financial impact by 65% percent within a single year through workflow optimization and cross-functional collaboration. In addition to her operational leadership, Angelica has earned national recognition for her contributions to the industry. She has been a frequent national speaker for the Association of Clinical Documentation Integrity Specialists, was honored with the ACDIS Professional Achievement Award and the MaHIMA Innovation and Collaboration Award in 2024 and served on the ACDIS Advisory Board. She is an active member of HFMA and AHDAM, contributing to thought leadership and the advancement of best practices in revenue cycle management. Reflecting on her new role, Cage shared, “Throughout my career, I have been passionate about advancing strategies that bring together the best of clinical expertise and operational performance. UASI is known for its ability to partner with providers in achieving sustainable results, and I look forward to contributing to that legacy by helping clients strengthen compliance, improve documentation and coding integrity, and enhance both financial outcomes and the quality of care delivered to patients.” Angelica’s appointment underscores UASI’s dedication to bringing forward-thinking leaders onto its team who can bridge clinical insight with operational strategy. By leveraging her expertise, UASI is well positioned to continue delivering innovative mid-revenue cycle solutions that drive compliance, efficiency, and financial performance while supporting the delivery of high-quality patient care. About UASI For over 40 years, UASI has bridged the gap between people and processes in financial and clinical operations by providing solutions that reduce revenue leakage, enhance operational efficiency, and ensure quality and compliance.

Rural hospitals are lifelines for millions of Americans but face unique operational, financial, and regulatory challenges. At the 2025 AHIMA Conference, Leah Jeffries, RHIT, CDIP, CCS, CCS-P, Managing Consultant at UASI, will present “The Nuances and Complexity of the Revenue Cycle Management of Critical Access Hospitals.” This session explores how Critical Access Hospitals (CAHs), small rural facilities designated by CMS, operate under different rules than larger hospitals. With up to 25 inpatient beds, distinct Conditions of Participation, and cost-based reimbursement, CAHs must balance strict requirements with financial stability while serving underserved communities. Key Takeaways Learn the history, purpose, and eligibility criteria of CAHs, including cost-based reimbursement and flexible billing options. Understand how Conditions of Participation differ from acute-care hospitals, covering bylaws, quality programs, infection control, and documentation standards. Explore cost-based reimbursement for inpatient, outpatient, and swing-bed services plus Method I and II billing for professional services. Discover common coding pitfalls unique to CAHs, from swing-bed and ambulance coding to anesthesia modifiers and charge validation. Gain strategies to improve documentation, reduce denials, and strengthen compliance despite limited resources. Looking Ahead There will also be a review recent and upcoming regulatory changes shaping rural healthcare. With over 140 rural hospitals having closed since 2005, attendees will leave equipped to protect reimbursement, improve revenue cycle processes, and sustain access to care. Critical Access Hospitals are more than healthcare providers; they are anchors for rural economies. This session offers actionable strategies to help CAHs thrive despite unique challenges. If you work in revenue cycle management, health information management, compliance, or clinical documentation, this is a must-attend session at AHIMA 2025. Sources: National Center for Biotechnology Information. (n.d.). Figure 22, Distribution of critical access hospitals in the United States, 2022. In 2022 National Healthcare Quality and Disparities Report. NCBI Bookshelf. U.S. Department of Agriculture, Economic Research Service. (n.d.). 146 rural hospitals closed or stopped providing inpatient services from 2005 to 2023 in the United States. ERS Charts of Note. Centers for Medicare & Medicaid Services. (n.d.). Critical Access Hospitals. Centers for Medicare & Medicaid Services. (n.d.). Medicare Claims Processing Manual, Chapter 2: Critical Access Hospitals (CMS Manual). Centers for Medicare & Medicaid Services. (n.d.). Critical Access Hospitals Center.

Summary of a Presentation by Rachel Mack, MSN, RN, CCDS, CDIP, CCS, CRC at the 2025 CHIMA Annual Meeting

UASI is proud to announce the appointment of Autumn Reiter as Chief Strategy and Solutions Officer. With 20 years of nursing experience, an MBA, and a decade of leadership in revenue cycle, payment integrity, and documentation improvement, Autumn brings a rare blend of clinical insight and strategic business expertise to the role. Autumn brings 20+ years of experience leading teams and delivering large scale solutions in CDI and Tech Enablement, Payment Integrity, and Provider Risk Strategies. Throughout her career, she has led large-scale programmatic builds, developed innovative solutions to optimize revenue capture, and implemented operational efficiencies that improved compliance and reduced costs for healthcare organizations nationwide. “UASI’s reputation for delivering exceptional results through strategic mid-revenue cycle solutions is unmatched in the industry,” said Reiter. “I am excited to join a team that shares my passion for bridging clinical care and business operations to drive quality, compliance, and operational excellence in healthcare reimbursement.” The addition of Autumn Reiter reflects UASI’s ongoing commitment to expanding its leadership team with seasoned industry experts who are dedicated to helping clients strategically optimize their revenue cycle, streamline operations, and enhance patient care. About UASI For over 40 years, UASI has bridged the gap between people and processes in financial and clinical operations by providing solutions that reduce revenue leakage, enhance operational efficiency, and ensure quality and compliance.

Why CMS Star Ratings Matter More Than Ever Hospitals are constantly measured on their quality of care, but few metrics carry as much weight as the Centers for Medicare & Medicaid Services (CMS) Star Ratings. These ratings influence how patients choose hospitals, how payers negotiate contracts, and how organizations position themselves in an increasingly competitive healthcare landscape. The Role of Star Ratings The CMS Star Ratings program evaluates hospitals across a wide range of quality measures. These include clinical outcomes such as readmissions and mortality, safety indicators like hospital-acquired conditions, and patient experience surveys addressing communication, responsiveness, and cleanliness. Hospitals receive an overall score that is highly visible to the public and payers. Impact on Patient Choice and Public Perception Patients want assurance that the care they receive will be safe and effective. Star Ratings serve as a shorthand for quality, guiding patient choice when selecting where to receive treatment. Hospitals with higher ratings often enjoy stronger reputations in their communities, while lower ratings can raise concerns about safety and performance. Influence on Reimbursement and Contracts Star Ratings are not just symbolic. They affect how hospitals are reimbursed, influence payer negotiations, and may unlock incentive payments for high performance. For many organizations, Star Ratings directly shape financial sustainability and the ability to reinvest in staff and technology. The Hidden Impact of Denials on Star Ratings Denials are often seen as a revenue cycle issue, but their impact goes far beyond delayed payments. When denials distort clinical data, they also undermine a hospital’s performance in CMS Star Ratings. Financial Consequences Every denied claim represents lost or delayed revenue. This directly reduces the resources available for quality initiatives, staffing, and patient experience improvements. Hospitals under financial strain may struggle to invest in areas that strengthen Star Ratings. Data Accuracy and Risk Adjustment Denials linked to documentation gaps or coding errors can lead to underreporting of patient complexity. Missed severity of illness and comorbidities affect risk adjustment, making outcomes such as mortality or readmissions appear worse than they are. Inaccurate data paints an incomplete picture of care quality. Denials influence critical Star Ratings measures, including: Mortality rates Readmission rates Complications Patient safety indicators When denials obscure true performance, hospitals risk lower ratings despite providing high-quality care. Operational Burden Staff rework and appeals consume time that could otherwise be dedicated to patient care, CDI initiatives, and proactive quality improvements. This operational distraction further hampers performance on Star Ratings measures. Organizations that do not address denial management place both their financial health and their public reputation at risk. By taking a proactive and comprehensive approach to denial prevention and management, hospitals can improve patient outcomes, protect vital revenue streams, and reinforce the trust and confidence of their communities and stakeholders. Turning Denial Prevention into Star Ratings Success Reducing denials is about more than revenue recovery. It is a strategic opportunity to strengthen documentation, improve data accuracy, and ultimately elevate CMS Star Ratings. Key Risks to Address Hospitals that do not proactively manage denials face three major risks: Missed capture of severity of illness and risk adjustment Underreported quality outcomes Reduced ability to invest in staff, technology, and patient experience Strategic Priorities for Hospitals Strengthen Documentation and Coding Accuracy: Clear, complete provider documentation ensures accurate code assignment and proper reflection of patient complexity. Proactively Manage Denials and Appeals: Early intervention prevents errors from cascading into distorted data and reduced reimbursement. Align CDI, Coding, and Revenue Cycle with Quality Measures: Collaboration across these functions ensures accurate reporting of outcomes and supports better ratings. Reinforce the Cycle of Accuracy: Accurate documentation leads to improved reimbursement, which enables reinvestment in quality initiatives, ultimately driving higher Star Ratings Connecting Quality and Finance Denial prevention directly supports quality outcomes, enhances reimbursement, and improves patient trust. By managing denials strategically, hospitals turn a traditional operational challenge into an opportunity for growth and leadership in value-based care. Resources: Centers for Medicare & Medicaid Services. (2024). Overall hospital quality star rating. CMS. https://www.cms.gov/medicare/quality/hospital-star-ratings Centers for Medicare & Medicaid Services. (2025). Transforming Episode Accountability Model (TEAM). CMS. https://www.cms.gov/priorities/innovation/innovation-models/team-model Centers for Medicare & Medicaid Services. (2024). Hospital quality star ratings methodology. CMS. https://qualitynet.cms.gov/inpatient/measures/hospital-star-ratings American Hospital Association. (2025). Denials management in hospitals. AHA. https://www.aha.org/topics/denials-management Centers for Medicare & Medicaid Services. (2024). Meaningful Measures 2.0: Moving to measure alignment. CMS. https://www.cms.gov/meaningful-measures-20 American College of Surgeons. (2025). Preparing for TEAM: Transforming Episode Accountability Model

For years, many Clinical Documentation Integrity (CDI) programs have focused heavily on financial metrics like DRG maximization, CC/MCC capture, and CMI shifts. While these numbers can be helpful for spotting trends, benchmarking, and understanding patient populations, they shouldn’t be the sole measure of success. When programs lean too much on these metrics, they risk stalling progress, losing physician engagement, and limiting long-term impact creating a band aid over the larger underlying issues. A stronger, more lasting approach puts clinical accuracy, provider education, and telling the complete patient story at the center, with financial results following naturally from doing the right work. The Limitations of the Traditional Model In a traditional CDI setup, much of the work happens after the fact. Queries go out once documentation is already complete, and success is judged by things like query volume, response rates, and short-term revenue gains. While this can boost the bottom-line short term the moment, it rarely fixes the real documentation gaps. For physicians, this approach often feels like an added layer of administrative work that interrupts their day and adds to compliance fatigue. Despite agreement among many CDI leaders that the focus needs to shift toward clinical understanding and root cause analysis of documentation and quality issues, the revenue-first model still dominates. Financial leaders often focus on revenue KPIs to gauge program performance, but these numbers tell only part of the story. While CDI must ultimately be financially viable, lasting success also depends on accurate reporting, quality outcomes, and better coordination of care. CDI 2.0: Building a Stronger Foundation The CDI 2.0 model focuses on clinical clarity, medical necessity, and improved communication across the care continuum. It blends clear, concise documentation into daily workflows and makes education for providers an ongoing priority formed from partnership with the CDI team. By working this way, documentation is improved at the source rather than adjusted after the fact. When CDI is positioned as a partner in improving patient care, physicians tend to see it as support rather than oversight. The result is documentation that paints a truer picture of the patient’s condition, which improves quality reporting, revenue integrity, patient safety, and collaboration across the care team. Putting Clinical Accuracy at the Core of CDI Organizations that embrace a clinically driven CDI model not only see stronger physician engagement but also achieve more lasting improvements in documentation. This connection is reflected in ACDIS’s Measuring and Valuing Quality survey, where nearly 60% of CDI professionals reported prioritizing Severity of Illness and Risk of Mortality measures ahead of purely financial outcomes. Similarly, the Optimized Comprehensive CDI Programs report found that 73% of respondents identified physician engagement and retention of education as key indicators of success, underscoring that sustainable CDI programs are built on clinical accuracy and provider partnership rather than short-term financial gains. This emphasis on clinical accuracy also extends to quality reporting. The ACDIS CDI and Quality Improvement survey showed that CDI teams track Present on Admission indicators (88%), Patient Safety Indicators (78%), and Hospital-Acquired Conditions (77%), highlighting how documentation accuracy supports organizational quality goals. Lastly, a recent exploratory analysis published in Health Services Research found that hospitals performing better on quality measures such as lower readmission rates, fewer complications, and higher patient satisfaction also tended to report stronger financial results (Carey and Burgess 2023). When CDI programs prioritize accuracy and completeness in the medical record, they not only strengthen clinical quality measures but also support long-term financial stability. Why Accuracy Leads to Better Outcomes As the healthcare landscape continues to evolve, CDI programs that focus on clinical accuracy will be best positioned to adapt and grow. When provider education, quality reporting, and financial performance are aligned around the complete patient story, CDI becomes more than a safeguard for revenue, it becomes a meaningful driver of better care. The future of CDI depends on programs that build physician trust, improve outcomes, and achieve financial stability as the natural result of accurate documentation. Need help transforming your CDI program? UASI offers staffing, assessments, quality audits, education, and more, all designed to elevate documentation accuracy, improve care quality, and uncover sustainable financial gains: https://www.uasisolutions.com/CDI References: ACDIS. Measuring and Valuing Quality. 2021, https://acdis.org/resources/measuring-and-valuing-quality . ACDIS. Optimized Comprehensive CDI Programs. 2023, https://acdis.org/resources/acdis-council-report-optimized-comprehensive-cdi-programs . ACDIS. CDI and Quality Improvement. 2023, https://acdis.org/resources/acdis-council-report-cdi-and-quality-improvement . Carey, Kathleen, and James Burgess. “An Exploratory Analysis of the Association between Hospital Quality Measures and Financial Performance.” Health Services Research, vol. 58, no. 6, 2023, pp. 1242–1252. PubMed Central, https://pmc.ncbi.nlm.nih.gov/articles/PMC10606508/ .

Yesterday, the Centers for Medicare & Medicaid Services released several final rules and updates impacting payment and quality expectations for FY 2026. Below is a summary of each announcement and its likely effect on providers across care settings. Quarterly Listing of CMS Program Issuances (April–June 2025) This listing compiles all CMS transmittals, memoranda, manual updates, and other instructions issued in the second quarter of 2025. While not tied to a specific payment update, it sets the compliance and operational agenda that contractors and providers need to follow going into the next fiscal year. Impact: Compliance leaders and revenue cycle teams should review the quarterly listing closely to ensure internal processes reflect the latest guidance on claims processing, provider enrollment, coverage determinations, and survey protocols. Link to announcement: https://www.federalregister.gov/documents/2025/08/05/2025-14822/medicare-and-medicaid-programs-quarterly-listing-of-program-issuances-april-through-june-2025 FY 2026 Hospice Wage Index and Payment Rate Update + Hospice Quality Reporting Program (HQRP) Changes CMS finalized a payment rate increase for hospices along with routine wage index updates. Revisions to HQRP continue the move toward outcome-oriented quality measurement, including preparation for the upcoming HOPE assessment tool. Impact: Hospices should expect modest payment growth coupled with expanded quality reporting expectations that will require stronger documentation and care coordination practices. Link to announcement: https://www.federalregister.gov/documents/2025/08/05/2025-14782/medicare-program-fy-2026-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting FY 2026 Inpatient Psychiatric Facility (IPF) PPS Final Rule This rule updates the IPF per diem base rate, wage index, and labor share for FY 2026. CMS also modifies several measures in the IPF Quality Reporting Program to put greater emphasis on behavioral health outcomes and performance improvement. Impact: Psychiatric hospitals and units will see a net payment increase, but must be ready to support enhanced quality tracking and accurate measure reporting to avoid penalties. Link to announcement: https://www.federalregister.gov/documents/2025/08/05/2025-14781/medicare-program-fy-2026-inpatient-psychiatric-facilities-prospective-payment-system-rate-update FY 2026 Inpatient Rehabilitation Facility (IRF) PPS Final Rule IRFs will receive a payment increase in FY 2026 tied to market basket and wage index changes. CMS also continues to strengthen the IRF Quality Reporting Program by refining functional outcome measures and signaling future alignment with post-acute value initiatives. Impact: IRFs should prepare for higher reimbursement alongside increased accountability for quality outcomes and performance on patient assessment data. Link to announcement: https://www.federalregister.gov/documents/2025/08/05/2025-14780/medicare-program-inpatient-rehabilitation-facility-prospective-payment-system-for-federal-fiscal Bottom Line for Providers CMS continues its trend of linking payment updates to quality, transparency, and data integrity. While most settings will enjoy FY 2026 reimbursement increases, each sector should be bracing for greater reporting rigor and operational alignment with value-based objectives. To stay ahead, providers should prioritize internal assessments of their current documentation, coding, and quality reporting workflows to identify any vulnerabilities, considering the new requirements. Investment in education, technology, and cross-functional collaboration will be essential to safeguard compliance, protect revenue, and successfully navigate the evolving value-based landscape.

CMS has identified a group of qualifying APM participants (QPs) from the 2023 performance year whose taxpayer identification numbers (TINs) are either missing or unidentifiable. As a result, CMS is currently unable to disburse the 3.5% APM incentive payments owed for the 2025 payment year. Action Required by September 1, 2025 To avoid forfeiting their incentive payments, affected QPs must: Submit their current Medicare billing information, including TINs, using the instructions provided in a separate notification from CMS. Ensure all relevant Quality Payment Program (QPP) data from the 2023 clinical performance period is submitted by September 1, 2025. Failure to provide the required information by the deadline will result in forfeiture of the APM incentive payment for the 2023 performance year. CMS has made a list of impacted QPs available and is urging all clinicians who expected to receive an APM incentive payment but have not yet received it to verify their status and submit the necessary documentation. Processing Timeline CMS will begin processing all timely submissions after the September 1 deadline. The validation and verification process may take up to three months before payments are issued. HIM leaders should take note because missed incentive payments can result in a significant loss of expected revenue, potentially up to 3.5% per qualifying clinician . Ensuring timely submission of TINs and quality data helps protect the organization’s reimbursement and supports compliance with value-based care initiatives. Proactively coordinating with clinicians and billing teams now can prevent revenue disruptions and strengthen your organization's performance under future APM reporting cycles. For questions, providers can contact the QPP Help Desk at 1-866-288-8292. To view the complete notice please visit: https://www.federalregister.gov/documents/2025/07/30/2025-14434/medicare-program-alternative-payment-model-apm-incentive-payment-advisory-for-clinicians-request-for

Hospitals can no longer focus exclusively on assigning the correct MS-DRG as value-based care (VBC) demands a more comprehensive approach that centers on complete, specific, and accurate documentation and coding. Reimbursement, quality rankings, and publicly reported outcomes now rely on data integrity at the patient level. The Shift to Value-Based Care Value-based care prioritizes quality over quantity. Payment models reward outcomes, care coordination, and patient experience rather than volume of services, and this transformation is reshaping inpatient payment strategies. According to CMS, over 90% of Medicare Advantage enrollees are now in plans that include some form of value-based payment model (CMS, 2023). Programs such as the Hospital Value-Based Purchasing (VBP) program adjust hospital reimbursement based on performance in key domains: mortality, safety, patient experience, and efficiency. Under the VBP program, CMS withholds 2% of base DRG payments and redistributes those funds based on performance scores (CMS VBP, 2024). Hospitals that perform well receive a net increase in payments and those that underperform lose a portion of their DRG reimbursement. These performance scores also feed into the CMS Star Ratings, impacting public perception, competitive standing, and contract negotiations with commercial payers. The Role of Accurate Coding Coding accuracy is foundational to success in value-based models. Accurate codes support appropriate reimbursement, enable risk adjustment, and fuel quality improvement efforts. They also ensure complete and defensible clinical documentation. Inaccurate or incomplete coding can exclude key diagnoses from risk models, skewing expected outcomes and exposing hospitals to financial penalties or public underperformance. Understanding Risk Adjustment Risk adjustment allows payers to compare patient outcomes across hospitals fairly by accounting for differences in patient acuity and comorbidities. CMS uses tools such as the Elixhauser Comorbidity Index to assess 30-day mortality, readmissions, and safety events. Diagnoses must be coded correctly and tagged as Present on Admission (POA) to be included. The mortality domain under the CMS Stars program includes seven metrics and evaluates all-cause mortality within 30 days. According to CMS, more than 3,000 hospitals receive mortality scores based on risk-adjusted data derived from claims and coded diagnoses (CMS Hospital Compare, 2024). Risk adjustment also influences private payers and rankings. U.S. News & World Report hospital rankings and Leapfrog scores incorporate risk-adjusted data derived from coded information. Missing a chronic condition like COPD, CKD, or diabetes may not impact the DRG but could dramatically alter performance scores and ranking outcomes. CDI, Coding, and Strategic Impact Clinical Documentation Integrity teams must prioritize specificity and relevance to risk models. This includes expanding review focus to non-mortality domains such as readmissions and complications. Coders and CDS specialists should be equipped to query not only for DRG optimization but also for clinical accuracy and data completeness. Hospitals that invest in this strategy see results. According to the AHIMA Foundation, hospitals with strong CDI programs report an average increase in captured comorbid conditions of 25–30%, resulting in improved risk scores, quality metrics, and reimbursement (AHIMA CDI Impact Study, 2023). Real World Example Consider the following inpatient scenario: A patient is admitted with new-onset atrial fibrillation (A-fib) that triggers acute congestive heart failure (CHF). Both conditions are evaluated, treated, and monitored during the admission. The provider documents both diagnoses clearly in the record, and clinical indicators support the acuity of each. At the coding level, two principal diagnosis (PDX) options are clinically valid: I48.91 (Unspecified atrial fibrillation) results in DRG 310, with a relative weight of 0.553 and a reimbursement of approximately $4,736 I50.9 (Unspecified heart failure) results in DRG 293, with a relative weight of 0.5615 and a reimbursement of approximately $4,795 Although CHF offers a slightly higher payment, it carries added risk in value-based care programs. Coding CHF as the PDX places this case in the CMS Heart Failure 30-Day Readmission Cohort, which is publicly reported and directly impacts a hospital’s readmission scores and star ratings. Coding A-fib, by contrast, avoids triggering that metric. Key takeaway for coders : Don’t make DRG assignment decisions in isolation. Collaborate with CDI and quality teams to understand downstream implications. Even small DRG differentials may lead to long-term financial risk if they adversely impact quality metrics. Be aware of cohort inclusion criteria tied to mortality, complications, and readmissions when selecting the principal diagnosis. When both conditions meet criteria for PDX, and documentation supports either as the focus of care, coders must weigh the immediate DRG return against long-term quality exposure. Query for specificity when it may influence cohort inclusion or risk adjustment, not just DRG grouping. From Code Assignment to Strategic Impact In today’s value-based care environment, coding professionals play a strategic role in shaping financial outcomes, quality performance, and public reporting. Accurate, complete, and specific coding is no longer just about selecting the highest-paying DRG. It is about capturing the full complexity of the patient’s condition, supporting risk adjustment models, and influencing quality domains that determine reimbursement, ratings, and reputation. Coders and CDI teams must operate as clinical and operational stewards, ensuring documentation supports both the clinical reality and the evolving expectations of payers and regulators. The future of hospital success depends on how precisely and thoughtfully each case is coded. Sources Centers for Medicare & Medicaid Services. “Hospital Value-Based Purchasing Program.” CMS.gov CMS Star Ratings Fact Sheet. “Overall Hospital Quality Star Rating.” CMS.gov AHIMA Foundation. “CDI Program Impact Report.” 2023. AHIMA.org Centers for Medicare & Medicaid Services. “2024 Medicare Advantage and Part D Rate Announcement.” CMS.gov Agency for Healthcare Research and Quality (AHRQ). “Elixhauser Comorbidity Index.” AHRQ.gov

The Centers for Medicare & Medicaid Services (CMS) has unveiled a sweeping expansion of its Medicare Advantage (MA) audit program, signaling a significant escalation in federal oversight. Under the new initiative, CMS will conduct annual audits of all 550 eligible MA contracts—a dramatic increase from the roughly 60 plans reviewed each year in the past. Additionally, the agency has committed to clearing a year-long backlog of audits, prioritizing unresolved payment reviews from 2018 through 2024, with a completion deadline set for early 2026. The announcement has sent shockwaves through the healthcare industry and financial markets, triggering swift backlash from major insurers. UnitedHealth Group and Humana—two of the largest Medicare Advantage (MA) providers—are now under heightened scrutiny, with UnitedHealth facing an active U.S. Department of Justice (DOJ) investigation into potential MA billing fraud. In an effort to preempt further regulatory action, both insurers have publicly endorsed reforms aimed at curbing the use of insurer-initiated home risk assessments. A controversial practice linked to inflated Medicare reimbursements. Analysts warn that such changes could reduce Medicare spending by as much as $124 billion over the next decade, dealing a significant blow to insurers that rely on these revenue streams. The expanded Medicare Advantage (MA) audit program marks a seismic shift in regulatory enforcement, fundamentally altering the compliance landscape for insurers and providers. Organizations must now brace for unprecedented documentation scrutiny, rigorous retrospective audits, and a far more aggressive federal oversight regime. To navigate this new reality, compliance programs require immediate reassessment, internal audit processes must be strengthened, and risk-sharing agreements should be reevaluated to mitigate the substantial financial and operational exposures stemming from this heightened oversight. Sources: Centers for Medicare & Medicaid Services. “CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits.” CMS.gov The Wall Street Journal. “Humana, UnitedHealth Back Limits on Medicare Billing Practices That Boost Revenue.” WSJ.com

As artificial intelligence reshapes healthcare, the accuracy and integrity of clinical data have never been more critical. At the heart of this transformation is Clinical Documentation Integrity (CDI), which is the process that ensures patient records are complete, accurate, and reflective of everyone's true clinical picture. CDI is more than a coding or compliance function; it directly influences the quality of data that drives analytics, informs patient care decisions, and feeds AI systems. Without precise documentation, AI models risk learning from flawed or incomplete narratives, which can perpetuate disparities rather than correct them. The quality of AI-driven healthcare is only as strong as the documentation behind it. This makes CDI a foundational element in the conversation about bias, representation, and equity in healthcare data and are issues that become even more urgent as technology plays a larger role in clinical decision-making.

Do these sentiments sound familiar? For those of you working in CDI, Coding, and/or Quality, you are likely aware of the dreaded Patient Safety Indicators (PSIs). For those of you newer to the CDI and Coding community, let’s take a moment to break it down. What are Patient Safety Indicators? PSIs are a set of measurement tools created by the Centers for Medicare & Medicaid Services (CMS) that track adverse patient outcomes. This article in particular focuses on the Inpatient space. Per the Agency for Healthcare Research and Quality (AHRQ), Patient Safety 101, “Safety” can be defined in healthcare as: “avoiding harm to patients from care that is intended to help them. It involves the prevention and mitigation of harm caused by errors of omission or commission in healthcare, and the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur.” 1 Patient safety was not at the forefront of healthcare until the late 1990’s when the Institute of Medicine (IOM) published the report, To Err is Human. This report estimated that nearly 44,000–98,000 patients die from preventable errors in American hospitals each year. 2 The body content of your post goes here. To edit this text, click on it and delete this default text and start typing your own or paste your own from a different source.

In the complex world of hospital reimbursement, the distinction between APR-DRGs and MS-DRGs can mean millions of dollars for healthcare organizations, particularly those serving pediatric populations. These two classification systems may appear similar at first glance, but their approach to severity adjustment creates significant variations in how patient cases are categorized and ultimately reimbursed. For children's hospitals and pediatric units, understanding these differences isn't just about coding accuracy—it's about financial survival in an era of tightening margins. The Critical Differences Between APR DRGs and MS-DRGs At their core, both APR DRGs (All Patient Refined Diagnosis-Related Groups) and MS-DRGs (Medicare Severity DRGs) serve the same fundamental purpose: to categorize hospital inpatient cases into groups that reflect similar clinical characteristics and resource utilization. However, the systems diverge sharply in how they account for patient severity. While MS-DRGs, used primarily by Medicare, employ a relatively simple three-tiered approach (no complications/comorbidities, with CCs, or with major CCs), APR DRGs introduce a more sophisticated four-level severity stratification (minor, moderate, major, and extreme) that also incorporates explicit risk of mortality measurements. This distinction becomes particularly crucial in pediatric care, where patients often present with complex, chronic conditions that don't fit neatly into Medicare's primarily adult-focused severity framework. A premature neonate with bronchopulmonary dysplasia, congenital heart disease, and feeding difficulties might be classified as a straightforward case under MS-DRGs but would be recognized as an extreme severity case under APR DRGs, with reimbursement differences that can exceed 30-40% for the same hospitalization. Why APR DRGs Matter for Pediatric Financial Viability The enhanced sensitivity of APR DRGs to pediatric complexity explains why many state Medicaid programs and children's hospitals have adopted this system. Pediatric cases often involve multiple interacting factors, including chronic conditions, developmental delays, nutritional challenges, and social determinants of health, which collectively drive resource utilization but may be overlooked in simpler classification systems. APR DRGs' four-tier severity structure enables more nuanced categorization that better aligns with clinical reality. Consider two hypothetical patients admitted for asthma exacerbation. Under MS-DRGs, both might be grouped similarly if they meet the MCC criteria. But APR DRGs would differentiate between a child with well-controlled intermittent asthma experiencing a first-time severe attack (likely moderate severity) versus a technology-dependent patient with severe persistent asthma, tracheostomy, and chronic respiratory failure (extreme seriousness). This granularity ensures hospitals caring for the most medically fragile children receive appropriate compensation for the intensive services these patients require. The Documentation Imperative: How CDI Bridges the Gap The financial implications of these classification differences make robust clinical documentation improvement (CDI) programs essential for pediatric providers. Effective CDI in the APR DRG environment requires moving beyond simple diagnosis capture to comprehensive illness characterization. Documentation must establish: The interplay between chronic conditions and acute presentations The cumulative impact of multiple comorbidities Precise severity assessments for each relevant condition Clear temporal relationships between conditions and treatments For example, documenting "respiratory failure" generates some severity credit, but specifying "acute hypoxic respiratory failure secondary to viral pneumonia in a patient with underlying severe bronchopulmonary dysplasia and pulmonary hypertension" paints the complete clinical picture needed for accurate APR DRG assignment. This level of detail doesn't happen by accident - it requires intentional collaboration among clinicians, CDI specialists, and coders. Strategies for Success in an APR DRG World Leading pediatric health systems have developed several best practices to optimize APR DRG performance: Condition-Specific Documentation Frameworks: Creating structured templates for common pediatric scenarios (extreme prematurity, complex chronic disease exacerbations, etc.) that prompt clinicians to address all relevant severity factors. Real-Time Physician Education: Embedding CDI specialists in clinical units to provide just-in-time feedback on documentation gaps as cases evolve. Enhanced Query Processes: Moving beyond yes/no queries to structured inquiries that help physicians articulate clinical complexity in reimbursement-relevant terms. Longitudinal Condition Management: Ensuring chronic disease registries and problem lists are accurate and updated at each encounter to support severity capture. Coder-Clinician Rounding: Facilitating direct communication between coding professionals and care teams to resolve ambiguities while clinical details remain fresh. The Bottom Line: Documentation as a Financial Lifeline For pediatric providers, particularly those relying on Medicaid reimbursement, mastering APR-DRG documentation isn't optional - it's a financial imperative. In an analysis of one children's hospital's case mix, transitioning from MS-DRG to APR-DRG classification increased average reimbursement by 22% for medically complex patients, directly attributable to more accurate severity capture. As payment models continue evolving toward greater risk adjustment, the ability to thoroughly document and code patient complexity will increasingly determine which pediatric programs can sustain the specialized services their patients need. The path forward requires breaking down traditional silos between clinical care and revenue cycle functions. When physicians understand how their documentation translates into resources for their programs, when CDI specialists speak the language of clinical care, and when coders have access to complete clinical pictures, everyone wins - especially the vulnerable pediatric patients whose care depends on these systems working seamlessly together.

Bridging the Gap: Why Pediatric Patients Matter in CDI

The mid-revenue cycle is often viewed as a financial and operational concern only —something for coders and documentation teams to manage. But when it breaks down, the consequences reach the boardroom. From missed revenue and rising denials to compromised patient trust and declining quality scores, C-suite leaders must recognize the mid-rev cycle as a critical lever of both financial and clinical performance. The mid-revenue cycle encompasses clinical documentation, medical coding, charge capture, and HIM. It’s the engine that translates clinical care into billable events. When mid-rev cycle isn’t optimized, the downstream effects are visible—not only in your A/R—but also to your patients, their experience and perception of your health system. When it fails, your organization feels the impact across four main pillars: Margin: The most obvious and direct area of impact is on the margin. Incomplete or inaccurate documentation leads to under-coding, denials, or missed reimbursement. Compliance: Misaligned documentation invites payer audits and potential penalties. Quality: Missed documentation can impact risk adjustment, mortality indexes, patient safety indicators and HCC capture—undermining value-based care metrics. Trust & Experience: Not as frequently talked about, but a priority for most health care leaders is the patient experience. A poorly run revenue cycle can result in billing confusion, delays in care, and communication breakdowns that erode loyalty. 

When most people hear “risk adjustment,” their minds jump straight to HCCs and Medicare Advantage. But that’s just one piece of a much larger puzzle. Today, risk adjustment plays a critical role not only in outpatient and ambulatory settings but also across inpatient care—and its impact goes far beyond reimbursement. It shapes hospital quality ratings, public perception, and even contract negotiations with commercial payers. For Clinical Documentation Integrity (CDI) professionals, this means one thing: it’s time to expand the lens. To truly protect their organizations and improve patient outcomes, CDI teams must think strategically about risk adjustment across all care settings—and understand how each setting contributes to the bigger picture of value-based care. Why This Matters: The Financial Stakes Have Never Been Higher As healthcare moves steadily from fee-for-service to value-based models, the financial consequences tied to quality metrics have become more severe. Programs like the Hospital Readmissions Reduction Program (HRRP) and Value-Based Purchasing (VBP) directly tie reimbursement to measures like 30-day mortality, readmissions, hospital-acquired infections (HAIs), and patient safety indicators (PSIs). In this budget-neutral world, CMS withholds a portion of payments—up to 3% under HRRP alone—and only hospitals that outperform national benchmarks get those funds back (and potentially more). This creates a high-stakes environment of financial “winners” and “losers,” where documentation accuracy and risk adjustment play pivotal roles in determining which side your organization lands on. Risk Adjustment: It’s About Leveling the Playing Field Risk adjustment ensures fairness by accounting for patient factors like age, chronic conditions, and overall disease burden. Without it, hospitals that care for the sicker, more complex populations would appear to have worse outcomes—penalized not for poor care, but for the very patients they serve. Tools like the Elixhauser Comorbidity Index and Vizient Clinical Database help calculate expected outcomes based on these patient complexities. This results in an Observed-to-Expected (O/E) ratio that tells the real story: a ratio below 1.0 signals better-than-expected performance; above 1.0 may indicate gaps in care—or gaps in documentation. CDI’s Expanding Role: From DRG Capture to Strategic Quality Management Historically, CDI teams focused on ensuring accurate documentation for MS-DRG assignment in hospitals and RAF scores in physician practices. But value-based care has raised the stakes. Accurate documentation now influences quality ratings (like CMS Stars and Leapfrog), public reporting, and even how organizations negotiate contracts with commercial payers. Take pulmonary hypertension as an example. This diagnosis may not impact the DRG assignment, but it significantly affects risk adjustment calculations for mortality and readmissions. Capturing it accurately changes how a hospital’s performance is judged—and could shield the organization from costly penalties. This is why CDI reviews must evolve beyond revenue capture. High-impact diagnoses that influence risk models need to be prioritized, even when they don’t change reimbursement directly. CDI professionals also play a vital role in ensuring that only appropriate cases enter mortality and readmission cohorts, directly affecting performance metrics. Understanding the Tools: Elixhauser, Vizient, and AHRQ Methodologies Different methodologies apply to different programs and understanding them is key to effective CDI intervention. Elixhauser Comorbidity Index: Used by CMS, focuses on 38 comorbidity categories derived from secondary diagnoses—many of which must be documented as present on admission. Vizient Clinical Database: Provides powerful benchmarking data, helping hospitals analyze performance and identify opportunities for quality improvement. Each methodology has its own nuances, but the common thread is this: documentation must be clinically valid, complete, and precise. Star Ratings and Public Perception: Why This Is About More Than Money CMS Star Ratings are public and highly visible. Patients use them. Payers use them. They directly influence a hospital’s reputation, competitive position, and even patient volumes. These ratings reflect performance across five domains: mortality, safety of care, readmissions, patient experience, and timely/effective care. A poor showing in just one domain—often influenced by incomplete documentation—can drag down an entire rating. Risk adjustment doesn’t just impact mortality rates; it influences penalties for readmissions, HAIs, and PSI reporting. Inaccurate or incomplete documentation skews these outcomes, exposing organizations to financial loss and public reputational damage. So, Where Should CDI Teams Focus? To make the biggest impact, CDI teams should prioritize reviews and queries that address: DRG Optimization – Capture CCs and MCCs accurately. Quality Measure Accuracy – Identify diagnoses that impact risk models for mortality and readmissions. HAC/PSI Prevention – Reduce exposure to costly penalties. Strategic Queries – Focus on high-leverage diagnoses that don’t always affect reimbursement but dramatically impact quality metrics. The Bottom Line: Accurate Data Drives Everything In the end, quality performance, financial success, and even public trust hinge on the accuracy of what’s documented and coded. CDI professionals aren’t just stewards of revenue anymore—they’re central to the organization’s strategy for thriving in a value-based world. As the healthcare environment grows more complex and margins shrink, the organizations that win won’t just deliver excellent care. They’ll also tell the full and accurate story of that care through precise documentation. And CDI teams will be the ones leading that charge.

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Why Health Information Professionals are Vital: 5 Key Insights

For Quality Directors, CMS Star Ratings are more than a metric—they reflect a healthcare organization’s commitment to excellence. A 4+ Star CMS rating directly influences plan revenue through quality bonus payments, increased member enrollment, and rebate retention. For Medicare Advantage organizations, even a one-star drop can mean millions in lost revenue, making high ratings essential for financial growth and long-term sustainability. While many factors influence ratings, documentation is the silent powerhouse that drives accuracy, compliance, and performance.

Hospitals today are navigating shrinking margins, workforce constraints, and increasing documentation scrutiny. For one national health system, years of revenue decline revealed a bigger issue: entrenched documentation practices were quietly costing millions. In partnership with UASI, this organization launched a system-wide CDI optimization initiative — spanning 42 hospitals — that not only delivered $100M+ in revenue improvement but also boosted quality scores, clinical accuracy, and physician engagement. Here's how we did it — and what other health systems can learn from it.