Top 10 Documentation and Coding Issues for Physician Practices in 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 changes Telehealth visits (audio and visual vs. telephone only); Medicaid behavioral health telehealth Review providers with higher than 10% of visits in level 4 and 5, or outliers…

Read More

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…

Read More

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:…

Read More

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…

Read More

FY 2022 ICD-10-CM Updates

Medical Coding

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…

Read More

The Role of a Physician Advisor

Given the heightened focus on documentation and impacts to healthcare organizations from both a financial and quality perspective, it is imperative that clinical documentation improvement (CDI) leaders implement an effective strategy to develop a physician advisor program. The success of a CDI physician advisor program hinges upon defining the physician advisor’s role. A physician advisor…

Read More

Mary Stanfill, Vice President of Consulting Services, Appointed as IFHIMA Rep to WHO-FIC

Mary Stanfill, Vice President of Consulting Services at UASI, was recently appointed as IFHIMA representative to the WHO Family of International Classifications (FIC) Education and Implementation (EIC) and Morbidity Reference Group (MbRG) workgroups. The position entails serving in an official capacity with voice and vote at WHO-FIC committees and upholding IFHIMA’s mission, vision and values,…

Read More