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    JustCoding Inpatient

    Unclear documentation fuels ongoing challenges in assigning appropriate POA indicator

    February 1, 2012
    The task of assigning the appropriate present on admission (POA) indicator for various conditions is still fraught with a number of challenges—many of which stem from problems coders have in obtaining clear, explicit physician documentation. Colleen Stukenberg, MSN, RN, CCDS, CMSRN, and Donna D. Wilson, RHIA, CCS, CCDS, discuss how gleaning the necessary details from the records can be a daunting task in and of itself, and then inconsistencies among various physicians makes assigning POA indicators that much harder.
    JustCoding Inpatient

    Use encoders alongside of critical reasoning and clinical knowledge

    February 1, 2012
    A coder can be misled when coding directly from an encoder, and heavy dependence on one can ultimately affect a coder’s skill set. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS, explains that a critical limitation of encoders is that they cannot physically reason. This inability to deduce often contributes to inaccurate ICD-9-CM code assignment at the expense of clinical accuracy in the reporting of disease processes, not to mention potential reimbursement and measures of continuity of care post-hospitalization.
    JustCoding Inpatient

    Permanent RAC program changes and new Medicaid program and pre-bill audit demonstration under way

    February 1, 2012
    Just when you thought you had your RAC processes in place, more changes appear on the horizon. CMS wasn't shy about making changes to the Medicare RAC program in 2011. For example, the second half of the year saw demand letters shift to become the responsibility of Medicare Administrative Contractors (MAC)—a change that went into effect January 3, 2012. Joseph Zebrowitz, MD, and Debbie Mackaman, RHIA, CHCO, comment on this change as well as other updates, including the RAC Statement of Work, the Medicaid RAC final rule, and the new pre-bill demonstration program.
    JustCoding Inpatient

    Healthcare News: CMS posts January issue of provider compliance newsletter

    February 1, 2012
    The January issue of Medicare Quarterly Provider Compliance Newsletter (volume 2, issue 2) addressed a number of recovery audit findings, including ambulance services separately payable during an inpatient hospital stay, diseases and disorders of the circulatory system, and minor surgery and other treatment billed as inpatient stay.
    JustCoding Inpatient

    Q&A: Coding for appendiceal stump syndrome

    February 1, 2012
    QUESTION: A physician admits a 30-year-old male with lower abdominal pain. A CT scan showed consistency with perforated appendicitis. However, the patient had an appendectomy 10 months prior. The physician documents "appendiceal stump syndrome." How should I code this case?
    JustCoding Inpatient

    POA Guidelines

    February 1, 2012
    JustCoding Inpatient

    Integumentary System Answer Key

    February 1, 2012
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