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. J ames S. Kennedy, MD, CCS, CDIP, Anita Rapier, RHIT, CCS, and Sharme Brodie, RN, CCDS, highlight some important advice from Coding Clinic.
Despite no recent changes from CMS, many providers still struggle with when to report modifier -25 (significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service) . Jugna Shah, MPH, explains how providers can review claims to determine if they are using the modifier correctly.
Most coding professionals have heard modifier -59 (distinct procedural service) referred to as a modifier of last resort and to be cautious in using this modifier.
Physicians often use the terms acute renal failure (ARF) and acute kidney injury (AKI) interchangeably to describe an abrupt decrease in kidney function that is reversible within three months of loss of function.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, explains how to identify anemia in documentation for OB/GYN patients and which ICD-9-CM and ICD-10-CM should be reported.
ICD-10-PCS does not include unspecified options so coders will need information for each of the seventh characters in the code. Cheryl Ericson, MS, RN, CCDS, CDIP, and Lynn Salois, RHIT, CCS, CDIP, review some of the areas where a surgical query might be needed.
Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, writes aboutwhat additional details coders will need to find in documentation to report pneumonia to the highest degree of specificity in ICD-10-CM and how to report it as a manifestation.
Shannon Newell, RHIA, CCS, Steve Weichhand, and Sean Johnson conclude their four-part series on PSI 90 with an in-depth look at PSI 12, which evaluates a hospital’s risk adjusted rate of perioperative deep vein thrombosis and/or pulmonary embolism in surgical discharges for patients 18 years and older.
