Each year the number of quality measures being used for public reporting across provider settings increases. Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA, and Linda Hyde, RHIA, explain why organizations that have not started to evaluate the impact ICD-10 will have on their quality measure data should start now.
To correctly assign codes for any surgical procedure, coders need to have an operative (OP) report. But simply having an OP report isn’t enough. Coders also must be able to read the OP report and pick out the important information. Lynn Pegram, CPC, CEMC,CPC-I, CGSC, breaks down the OP report to help coders find the information they need.
During the last year, the buzz from the health information management (HIM) and coding community has consistently reflected that, as a whole, the industry continues to feel the strain of tight budgets and squeeze of limited resources, especially with the approach of ICD-10 implementation. Coders reacted to the effects this has had on their compensation levels in the 2011 JustCoding Coder Salary Survey, the results of which are also discussed.
Our coding experts answer your questions about molecular pathology codes, HCPCS codes for drugs that aren’t separately payable under OPPS, deducting push time from infusions, CPT initial observation codes, and diabetes coding in ICD-10-CM.
Coders are constantly analyzing documentation for clues and details that may indicate the need for a physician query. For example, coders should watch for clinical evidence that points to a condition that the physician may not have explicitly documented. Coders also need to be wary of reporting conditions without accounting for context or other clinical indicators in the documentation. William E. Haik, MD, CDIP, explains how this can lead to inappropriate reporting of an MCC, for example, that the overall clinical picture does not support.
Physicians use a lot of shortcuts and abbreviations. Some of them may even make it onto the official abbreviation list at their hospital. Some don’t. And even if they did, some physicians will use the wrong term. Robert S. Gold, MD, discusses an example that was featured in the January Medicare Quarterly Provider Compliance Newsletter regarding proper identification and ICD-9-CM coding of a bronchoscopy with biopsy (TBB) vs. a bronchoscopic lung biopsy (TBLB).
The respiratory system, responsible for inspiration (carrying oxygen into the body) and expiration (the expulsion of carbon dioxide), is composed of two tracts: the upper respiratory tract and the lower respiratory tract.
Coders who keep in mind the injuries that define multiple significant trauma are more likely to identify these cases and assign DRGs based on this classification when present. Joel Moorhead, MD, PhD, CPC, and Beverly (Cross) Selby, RHIT, CCS, examine what defines multiple significant trauma and discuss the coding guidelines for these sometimes complicated cases.
