Coders prepared for 2017 with numerous changes to the Official Coding Guidelines for the ICD-10-CM and the addition of many new codes. Quietly waiting in the wings was the updated CPT® Manual for 2017 with its changes waiting to be discovered.
Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and sometimes vague rules.
The focus for clinical documentation improvement (CDI) specialists has historically been on the inpatient hospital stay. Review of the chart for conditions that are not fully documented and/or evidence of conditions not documented at all has been standard practice.
With a new year underway, providers likely need to get a handle on some key new modifiers, as well as important changes to an existing modifier and the deletion of a modifier that previously raised a lot of questions and operational concerns.
The 2017 ICD-10-CM updates included a significant number of additions to digestive system diagnoses, especially codes for pancreatitis and intestinal infections. These codes are largely focused in the lower gastrointestinal (GI) tract, and a review of the anatomy of this body system could help improve accurate documentation interpretation and code selection.
Managers should not assume that they can review every guideline, every item in Coding Clinic , or every coding-related issue targeted by the Office of Inspector General (OIG) or Recovery Audit Contractor (RAC).
by Stacie L. Buck, RHIA, CCS-P, CIRCC, RCC One area of CPT coding that saw big changes for 2017 is for dialysis circuit coding. The existing codes have all been deleted, and new codes have been...
