While we know the implementation date of ICD-10 may change to the proposed 2014 deadline, healthcare organizations must keep moving forward with preparations. Annie Boynton, BS, RHIT, CPC, CCS, CPC-H, CCS-P, CPC-P, CPC-I, CPhT, explains how organizations can use the additional time to better handle the change process associated with ICD-10, especially planning for education and training.
Each year the number of quality measures being used for public reporting across provider settings increases. Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA, and Linda Hyde, RHIA, explain why organizations that have not started to evaluate the impact ICD-10 will have on their quality measure data should start now.
During the last year, the buzz from the health information management (HIM) and coding community has consistently reflected that, as a whole, the industry continues to feel the strain of tight budgets and squeeze of limited resources, especially with the approach of ICD-10 implementation. Coders reacted to the effects this has had on their compensation levels in the 2011 JustCoding Coder Salary Survey, the results of which are also discussed.
Coders are constantly analyzing documentation for clues and details that may indicate the need for a physician query. For example, coders should watch for clinical evidence that points to a condition that the physician may not have explicitly documented. Coders also need to be wary of reporting conditions without accounting for context or other clinical indicators in the documentation. William E. Haik, MD, CDIP, explains how this can lead to inappropriate reporting of an MCC, for example, that the overall clinical picture does not support.
Physicians use a lot of shortcuts and abbreviations. Some of them may even make it onto the official abbreviation list at their hospital. Some don’t. And even if they did, some physicians will use the wrong term. Robert S. Gold, MD, discusses an example that was featured in the January Medicare Quarterly Provider Compliance Newsletter regarding proper identification and ICD-9-CM coding of a bronchoscopy with biopsy (TBB) vs. a bronchoscopic lung biopsy (TBLB).
Coders who keep in mind the injuries that define multiple significant trauma are more likely to identify these cases and assign DRGs based on this classification when present. Joel Moorhead, MD, PhD, CPC, and Beverly (Cross) Selby, RHIT, CCS, examine what defines multiple significant trauma and discuss the coding guidelines for these sometimes complicated cases.
Coders should already be familiar with the 285 new, revised, and deleted ICD-9-CM codes that CMS finalized for fiscal year (FY) 2012. However, it’s critical that providers also examine how these changes directly affect MS-DRG assignment. Robert Gold, MD, examines a number of these changes, including MS-DRG assignment related to cardiac-specific comorbidities, autologous bone marrow transplants, excisional debridement, and thoracic aneurysm repair.
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP, writes about the importance of tracking venous thromboembolism at hospitals and how to ensure physician documentation includes the correct level of detail to capture it.
Coders need to understand the clinical presentation of sepsis to report it accurately. Robert S. Gold, MD, and Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, review how to identify sepsis and tips for coding it in ICD-10-CM.
ICD-10 may be a new system with thousands of additional codes compared to ICD-9-CM, but that doesn’t mean it can still accurately report every clinical scenario. Robert S. Gold, MD, identifies conditions that aren’t necessarily represented by the codes available.