E/M reporting remains challenging for coders and an area of scrutiny for auditors. These challenges can be amplified in the ED, but coders can reduce confusion by reviewing rules for reporting critical care and other components.
Facilities may not yet be using clinical documentation improvement staff to review outpatient records, but the increasing number of value-based payment models and Medicare Advantage patients could make the practice worthwhile, according to Angela Carmichael, MBA, RHIA, CDIP, CCS, CCS-P, CRC, and Lena Lizberg, BSN.
Q. Since ICD-10-CM code O24.415 (gestational diabetes mellitus in pregnancy, controlled by oral hypoglycemic drugs) has been added for 2017, do we need to add which specific drug is being used by the patient when reporting the code?
The new ICD-10-CM codes activated October 1 affect nearly every section of the manual. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about codes that impact genitourinary and gynecological diagnoses with tips for reporting them accurately.
CMS released the final rule implementing provisions of the Medicare Access and CHIP Reauthorization Act of 2015 on October 14, giving providers a timeline and outline of the quality programs and payment models that will replace the Sustainable Growth Rate and other programs.
