Coders may find assigning codes for sepsis somewhat easier in ICD-10-CM, but they will still face some challenges. The first of those challenges, and probably the biggest, centers on physician documentation.
CMS released its FY 2014 IPPS final rule in August, and with it comes a whole slew of changes for inpatient hospitals. Set aside a good amount of time to scroll through the 2,000-plus page document. Yes, that's right: There are more than 2,000 pages of information to absorb before the rule goes into effect on October 1, 2013.
Do EHRs enable fraud and abuse by encouraging upcoding? What other factors could have led to higher levels of E/M coding over the past decade? Who or what organizations are responsible for ensuring compliance?
Auto manufacturers rely on them to make decisions about improving passenger restraints in vehicles. Industrial engineers may reference them when advocating for improved design of staircases to prevent falls. Drug companies use them to bolster support for child-resistant packaging.
William E. Haik, MD, FCCP, CDIP, a practicing pulmonologist and director of DRG Review, Inc., in Fort Walton Beach, Fla., says he first became interested in coded data in 1986 after a local newspaper published his hospital’s costs, length of stay, and mortality rates for simple pneumonia. At the time, he was the only pulmonologist in the local area. The patients he treated were often those with multiple comorbidities as well as gram-negative bacterial pneumonia who had been transferred from two smaller facilities in the county.
DRGs for procedures unrelated to the principal diagnosis shouldn't occur frequently. If they do, coding managers should take a closer look at coding compliance efforts to ensure accuracy and avoid costly audits.
Everyone knows that CCs and MCCs are under scrutiny these days. However, that doesn't mean hospitals should err on the side of caution when reporting these conditions. William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla., provides several tips that coders can employ to look for clinical evidence in the record before querying for these targeted conditions.
As Lucile Packard Children's Hospital in Palo Alto, Calif., implemented its EHR, the dreaded problem of copy and paste documentation began to rear its ugly head.