In the 2018 OPPS final rule, CMS removed total knee arthroplasty (TKA) from the inpatient-only (IPO) list effective January 1, 2018. Although some guidance was provided at the time, providers and physicians alike were left confused with a significant number of questions regarding documentation and inpatient status
Coding for knee arthroscopies can be challenging, especially when procedures are performed in multiple compartments of the same knee. Read about anatomy and coding details required to accurately report these procedures.
Modifier -JW is used to describe drug amounts that are discarded and not administered to any patient. This does not reduce the payment for the drugs, so this is an informational modifier, but it is a mandatory modifier.
Pay close attention to new CPT documentation and coding guidance for reporting radiological imaging. For example, a new paragraph titled “Imaging Guidance” in both the surgery and medicine guidelines advises that even when imaging guidance or supervision are included in a surgical procedure code, you must still follow the radiology documentation requirements in the CPT manual.
In 2018, most organizations held the line on coder productivity, according to the results of sister publication HIM Briefings’ 2018 coding productivity survey.
Establishing an outpatient CDI program can have substantial benefits. Recently, an outpatient CDI review project demonstrated there were many documentation improvement opportunities at a large family practice/internal medicine physician clinic.
