Inpatient coding professionals must have a clinical understanding of COVID-19 and the disease process in order to accurately sequence diagnoses, code etiology and manifestations, and assign present on admission (POA) indicators. In this article, Audrey Howard, RHIA , and Susan Belley, RHIA, CPHQ, focus on coding issues related to POA indicators for the hospitalized, inpatient COVID-19 population.
Howard Rodenberg, MD, MPH, CCDS , writes that ensuring the social determinants of health are appropriately documented within the medical record allows CDI and coding teams to capture the hard data needed to demonstrate the interactions among race, gender, ethnicity, and other key socioeconomic indicators with healthcare costs, utilization, and outcomes.
The Office of Inspector General (OIG) recently released an audit report for Providence Medical Center that says some of the hospital’s inpatient records did not support the medical necessity for inpatient hospital services.
Review clinical indicators and query opportunities for acute respiratory failure, respiratory failure due to surgical procedures, and ventilator MS-DRGs. Frequently reviewing clinical indicators for these complicated diagnoses will ensure both proper coding and reimbursement. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: When two conditions are both present on admission, both meet definition to be the principal diagnosis (PDX), and are “equally treated,” my understanding is that the condition does not have to be "equally treated" in the sense of duration/frequency. Can you provide the actual verbiage of the coding rule and explain?
Both sepsis and malnutrition remain top denied diagnoses, and there is little sign of those denial rates slowing. This article is part two of a two-part series that zeros in on clinical validation and denial prevention for these two diagnoses.
Those afflicted with sickle-cell disease or sickle cell traits were more likely to experience severe COVID-19 illness and hospitalization, according to a recent study presented at the American Society of Hematology Annual Meeting and Exposition.
Sarah Nehring, RHIT, CCS, CCDS, writes that the ICD-10-PCS code set update for fiscal year 2021 included the creation of five new Fragmentation tables. For this article, Nehring will take a look at two vascular Fragmentation procedures: ultrasound-assisted thrombolysis (EKOS) and intravascular shockwave lithotripsy (IVL). Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: Was there an Excludes note change for subcategory G93.4- (other and unspecified encephalopathy) for fiscal year 2021? If so, how will it change any ICD-10-CM reporting and reimbursement for toxic encephalopathy and metabolic encephalopathy going forward?
In a year of unprecedented disruption and uncertainty, coding productivity managed to hold steady, according to the results of HCPro’s 2020 Coding Productivity Survey. Review the survey results, which provide data on facility coding productivity, accuracy benchmarks, and more.