Documentation Tips

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 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…

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…

2021 Documentation and Coding Compliance Tips

By Staff / May 24, 2021

Click the button below to download UASI’s latest Top 10 Tips for your compliance plan:

UASI Compliance Work Plan Analysis – Inpatient Documentation and Coding Issues

By Natalie Sartori / April 1, 2021
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By: Natalie Sartori, M. Ed., RHIA, CCS This whitepaper is the first in a 2-part series regarding UASI inpatient and outpatient analyses of third party compliance work plans (including the OIG and RACs for example). This document details an analysis of the following active inpatient topics: Medicare Payments for Inpatient Discharges with COVID-19 (OIG) Deep…

FY21 E/M Office Visit MDM Part 3: Risk of Complications and/or Morbidity/Mortality

By Staff / February 17, 2021

UASI is on the front lines actively working with our clients to help them comply with the biggest change in evaluation and management (E/M) coding since 1997. The new office visit E/M code levels are assigned based on either medical decision making (MDM) or total time. The complex MDM rules make it really easy to…

FY21 E/M Office Visit MDM Part 2: Amount/Complexity of Data Reviewed

By Staff / February 17, 2021

UASI is on the front lines actively working with our clients to help them comply with the biggest change in evaluation and management (E/M) coding since 1997. The new office visit E/M code levels are assigned based on either medical decision making (MDM) or total time. The complex MDM rules make it really easy to…

FY21 E/M Office Visit MDM Part 1: Number and Complexity of Problems

By Staff / February 17, 2021

UASI is on the front lines actively working with our clients to help them comply with the biggest change in evaluation and management (E/M) coding since 1997. The new office visit E/M code levels are assigned based on either medical decision making (MDM) or total time. The complex MDM rules make it really easy to…

UASI Analysis of the OIG Work Plan February 2020

By Natalie Sartori / February 1, 2020
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By: Natalie Sartori M.Ed., RHIA, CCS This white paper presents an analysis of new and ongoing initiatives under the OIG Work Plan as of February 2020.[1] The paper focuses on initiatives related to HIM coding and documentation requirements and is not intended to review each and every active work plan item. Overlapping active work plan…