Jillian Harrington, MHA, CCS, CCS-P, CPC, CPC-P, CPC-I, MHP, reviews the components in operative reports coders will need to find in order to report ICD-10-PCS codes for spinal fusions.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about the section added to ICD-10-PCS for 2016 for reporting new technology procedures.
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.
CMS finalized its proposals regarding the 2-midnight rule in the 2016 OPPS final rule, including moving responsibility for enforcement and education of the rule from Recovery Auditors to Quality Improvement Organizations (QIO). This latter change occurred October 1, 2015.
Q: Is there guidance on reviewing a record, such as an operative note, that has not been signed by a physician? I am at a facility that allows coding from unsigned transcriptions. I was always told that the information needs to be confirmed by a signature as valid before including that information in the review worksheet. Do you have any recommendations for this?
