Greek philosopher Heraclitus once said the only constant is change. With the release of the fiscal year (FY) 2019 IPPS proposed rule , and all of the changes it contains, CMS has certainly proven Heraclitus correct. The rule applies to 3,257 acute care hospitals, and once finalized, will affect discharges on or after October 1.
In inpatient coding, all diagnoses that affect the current hospital stay must be reported. In addition, the Uniform Hospital Discharge Data Set is commonly followed for reporting secondary diagnoses; it says that other (or additional) diagnoses are defined as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay."
When building a successful proactive clinical documentation approach, the effort of setting up communication dynamics is essential and should certainly be a priority.
Though larger facilities may have had CDI programs for years that work in conjunction with the inpatient coders—some for over a decade—others are only starting now.
Spinal surgery is big business. The global market was expected to reach $9.3 billion by 2017, according to Global Industry Analysts . Coders can certainly attest to the frequency of these procedures.
Inpatient coding audits are performed for different purposes by individuals within and outside of the hospital. Coding audits can be categorized in various ways as shown below, but these attributes are not exclusive: Audits will have several characteristics at a time.
It is well known that ICD-10-CM/PCS code assignment impacts hospital reimbursement and compliance; however, there is an additional code that often flies under the radar for inpatient coders—the discharge status code. Inaccurate discharge status code assignment for Medicare post-acute care transfers (PACT) can lead to under reimbursement and compliance risks for hospitals.
The thyroid gland, included in the endocrine system, is a small gland located at the base of the neck. Although small when compared to the other components of the endocrine system, the thyroid gland plays a significant role in overall body function, influencing the performance of the heart, brain, liver, kidneys, and skin.
I was recently reviewing Coding Clinic , First Quarter 2018, and felt that the question regarding physeal fractures needed more clarification and explanation than was provided in the official answer.
The implementation of an EHR is a multifaceted, comprehensive project for healthcare organizations. Though it affects every department and function in some way, the impact on medical record coding may be the most profound and complicated, with some organizations reporting a 20% decrease in coding productivity after EHR implementation.
