Ask a physician why he or she documents in the medical record and you'll get a variety of answers. Some physicians will say they document because the medical records people hound them for the information, or they do it so they get paid. They may also say they do it to complete the medical record.
Betty Hovey, CPC, COC, CPB, CPMA, CPC-I, CPCD, and Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, review anatomy details of the heart and how to report ICD-10-CM codes for atherosclerosis and conduction disorders.
With fewer than 100 days until ICD-10-CM/PCS implementation, plenty of questions still remain about ICD-10-PCS coding. The AHA's Coding Clinic for ICD-10 continues to provide updates and guidance for a variety of inpatient procedures, both routine and not so routine. We examine some of that guidance in this article.
In an effort to accommodate the latest advances in technology and make the code set easier to modify for future technological changes, the AMA extensively overhauled codes for reporting drug testing in the 2015 CPT ® Manual.
Cardiac conditions are some of the most common diagnoses seen in hospitals. Betty Hovey, CPC, COC, CPB, CPMA, CPC-I, CPCD, and Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, review coding conventions and documentation details for reporting heart failure and angina in ICD-10-CM.
Sharme Brodie, RN, CCDS , highlights guidance on ICD-10-PCS root operations and seventh characters for ICD-10-CM from the latest issue of Coding Clinic .
The April quarterly I/OCE update from CMS did not defy convention?featuring the typically small number of updates following extensive changes in the previous quarter?but CMS did continue to clarify the logic for comprehensive APC (C-APC) payments.
ICD-10-CM will still allow coders to report unspecified codes. However, coders will not have that option in ICD-10-PCS. Every character has to have a value, which will lead to an increase in surgical queries.
