We’ve survived the holiday feast and decided to skip the doorbusting to head out and visit the cute and fluffy animals at the Anytown Zoo. Of course, no outing would be complete without some injuries...
Tom Turkey has come in to the Stitch ‘Em Up Hospital for a little work before Thanksgiving. Dr. Carver is going to first take out Tom’s guts, then replace them with stuffing. How would we code Tom’s...
The major revisions to the coding guidelines for office/other outpatient evaluation and management visits are almost four years old. And yet, practices continue to face challenges when they document and report these services. This article outlines four actions to avoid and four challenges that practices face when they report these high-value, high-volume services.
Black Book Research recently surveyed more than 4,000 health information management professionals about their concerns for the new year. Find out what issues are at the top of their minds for 2025.
Physicians and other qualified healthcare professionals have the flexibility to select an evaluation and management level based on either the complexity of medical decision-making or the total time spent on the date of the encounter. This article covers documenting E/M services based on time. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Level-based evaluation and management services may be coded based on medical decision-making (MDM). To reach a code based on MDM, the documentation must support at least two out of the three elements. This article covers the first element: number and complexity of problems addressed at the encounter.
Genetic medicine is an emerging specialty coders will be faced with, and a basic foundation of the science and consequences of genetic anomalies will be helpful going forward. Realizing coders are not expected to be clinical, Nancy Reading, RN, BS, CPC, CPC-P, CPC-I , shows how it will still be useful to know the basics.
Q: A female patient previously had an inpatient stay due to severe enteritis secondary to the use of Keytruda for colon cancer that she was diagnosed with six months earlier. While she has had positive results to the medication, she presented to the ER last week due to severe abdominal bloating and cramping with diarrhea and stools with large amounts of mucous. She was dehydrated and hypokalemic upon inpatient admission and has a history of depression. Her discharge note indicates that her potassium levels and dehydration are normalized. How would this encounter be reported in ICD-10-CM?
If denials are not going anywhere anytime soon, increasing at an alarming rate, and causing organizations to close, how do hospitals ameliorate this issue? Hospitals, including coders, can work to stem it by understanding the different types of denials, the problems they pose, and the tactics required to fight them.
