Top 10 Documentation and Coding Issues for Hospitals in 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…

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CDI Outpatient Practice Director

We are expanding our CDI services by hiring an Outpatient CDI Practice Director. We are seeking a subject matter expert with both clinical and HIM coding/billing experience in an ambulatory setting, specifically within a physician practice/clinic environment.

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FY 2022 IPPS MS-DRG Final Rule Updates

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…

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CY 2022 OPPS Proposed Rule

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…

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Shock CDI Scenario – August 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:…

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FHIMA 2021 Recap

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…

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