If coders choose the wrong root operation in ICD-10-PCS, they will arrive at an incorrect code. Nena Scott, MSEd, RHIA, CCS, CCS-P, AHIMA-approved ICD-10-CM/PCS trainer, Gretchen Young-Charles, RHIA, Anita Rapier, RHIT, CCS, and Nelly Leon-Chisen, RHIA, discuss some of the root operation clarifications offered by Coding Clinic .
In part 2 of his series on medical necessity and coding, Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, examines medical necessity and the 2-midnight rule using a case study.
CMS proposed a major change to physician certification requirements in the 2015 OPPS proposed rule. Kimberly A.H. Baker, JD and James S. Kennedy, MD, CCS, CDIP, break down how the change could affect inpatient admissions.
When a patient comes in contact with a drug or chemical that has an unhealthy effect, coders will have an easier time reporting it in ICD-10-CM than in ICD-9-CM. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer reviews poisoning and adverse effect coding in both code sets.
Coders use different codes to report traumatic and pathologic fractures. Robert S. Gold, MD, and Kristi Stanton, RHIT, CCS, CPC, CIRCC, highlight the differences in coding for the two etiologies of fractures in both ICD-9-CM and ICD-10-CM.
CMS designates certain procedures as inpatient-only, meaning it will only reimburse the facility when the procedure is performed on an inpatient. However, CMS identifies these procedures using outpatient CPT ® codes. Beverly Cunningham, MS, RN, and Kimberly A.H. Baker, JD, CPC, discuss the process for identifying and coding inpatient-only procedures.
Learning to code in ICD-10-PCS is in some respects like learning a language, you need a strong foundation in the rules. Sue Bowman, MJ, RHIA, CCS, FAHIMA , Gerri Walk, CCS-P , Nena Scott, MSEd, RHIA, CCS, CCS-P , and Jennifer Avery, CCS, CPC-H, CPC, CPC-I, discuss the guidelines related to root operations in ICD-10-PCS.
Both knee and shoulder replacement procedures include devices and fall under the ICD-10-PCS root operation Replacement (R). Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, and Nena Scott, MSEd, RHIA, CCS, CCS-P , review the definition of a device in ICD-10-PCS and review how to code for shoulder and knee replacements.
Coders can only use the documentation they have to code in ICD-9-CM and ICD-10-CM. Adelaide La Rosa, RN, BSN, CCDS, and Deborah Lantz, RHIA, discuss the importance of good documentation when coding for fractures and congestive heart failure in both systems.
Pneumonia is an inflammatory process that affects the lung tissue. Robert S. Gold, MD , and Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, explain the clinical and documentation pieces of pneumonia coding.