Insights + Education

Top 10 Documentation and Coding Issues for Physician Practices in 2021

By Staff / September 1, 2021

Make sure you are addressing these top documentation and coding compliance concerns. Risk-based review of evaluation and management codes (E/M):Appropriate application of FY21 E/M code guideline changesTelehealth visits (audio and visual vs. telephone only); Medicaid behavioral health telehealthReview providers with higher than 10% of visits in level 4 and 5, or outliers on E/M bell…

Top 10 Documentation and Coding Issues for Hospitals in 2021

By Staff / August 25, 2021

Make sure you are addressing these top documentation and coding compliance concerns. Risk-based review of inpatient DRG cases, examples include: RAC DRG targets; PEPPER targeted DRGs COVID related inpatient discharges Clinical indicators, cases at risk for clinical denials (e.g. Sepsis, CHF, ARF, severe malnutrition, encephalopathy) IP cases with only 1 MCC/CC code or HAC/PSI cases…

Reporting Percutaneous Ventricular Assist Device Insertion – August 2021 Coding Tip

By Marcy Blitch / August 18, 2021

Learn more about codes 33995 and 33997, which are new to the 2021 Current Procedural Terminology (CPT).

FY 2022 IPPS MS-DRG Final Rule Updates

By Mary Stanfill / August 9, 2021

The annual final rule from the Centers for Medicare and Medicaid Services (CMS) regarding the Inpatient Prospective Payment System (IPPS) MS-DRGs was issued on August 2, 2021. [1] This final rule is effective October 1, 2021. [2] It was proposed in April that 3,490 unspecified diagnosis codes currently designated as either CC or MCC would…

CY 2022 OPPS Proposed Rule

By Mary Stanfill / August 9, 2021

On July 19th the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2022 Outpatient Prospective Payment System (OPPS) proposed rule. [1] After a comment period, the final rule will be published in November 2021. Notable changes proposed for CY 2022 include: A net increase in OPPS payment rates of 2.3% over…

Shock CDI Scenario – August 2021

By Staff / August 5, 2021

H&P: 58 yr old male with chest pain and SOB presents to the ER. Troponins ordered along with EKG revealing nonspecific ST changes with rising levels. Cardiology consult for NSTEMI with orders for ASA 325mg x1, Nitropaste, and o2. While waiting on consult, patient became lethargic and pale with fingertip cyanosis noted. Repeated VS showed:…

FHIMA 2021 Recap

By Staff / August 2, 2021

The 2021 Florida Health Information Management Association (FHIMA) Annual Convention took place July 19-21 in Orlando. UASI sent Regional Market Manager Brad Allen, Vice President of Strategic Initiatives Michael Burke, and Vice President of Corporate Development Nancy Koors to the Sunshine State in order to catch up with Florida HIM professionals. Although the Convention was…

New FY22 Code: Non-Traumatic Cardiac Injury

By Natalie Sartori / July 28, 2021

With the current ICD-10-CM code set, there is no specific code corresponding to non-traumatic myocardial injury. Given the high severity of illness typical of patients with non-ischemic myocardial injury, appropriate classification of these patients is paramount in terms of aligning appropriate diagnostic and treatment strategies while avoiding inappropriate approaches that would otherwise be suggested by…

New FY22 Code: Gastric Intestinal Metaplasia

By Natalie Sartori / July 15, 2021

Intestinal metaplasia (IM) occurs when cells in the tissues of the upper digestive tract, often in the stomach or esophagus, change and become more like cells from the intestines. Intestinal metaplasia in the esophagus is also called Barrett’s esophagus. Intestinal metaplasia is more common in people who have chronic acid reflux or gastroesophageal reflux disease (GERD). The…

FY 2022 ICD-10-CM Updates

By Staff / July 13, 2021

Abnormal Findings on Neonatal Screening Currently there is only a single code to capture any or all types of newborn screenings that may have positive or abnormal results. The American Academy of Pediatrics requested expansion of category P09 Abnormal findings on neonatal screening, to specifically show which screening categories were abnormal. Table 1 shows the…