After a cerebrovascular accident (CVA, also known as stroke), a patient may suffer additional health problems, lasting after the event has passed. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, compares coding for these lasting effects, known as sequela, in ICD-9-CM and ICD-10-CM.
When it comes to ICD-10-CM/PCS, coders may be the hardest and most directly hit employees. Yet some experts say that aside from technical training, hospitals may be lagging behind in terms of actually managing the change for these individuals.
The 2014 OPPS proposed rule is shorter than normal at 718 pages, but the proposed changes are significant and probably the most sweeping changes since the inception of OPPS, says Jugna Shah, MPH, president and founder of Nimitt Consulting.
Diagnostic conclusion statements don’t sufficiently capture the clinical context and medical necessity for inpatient admission. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, discusses the importance of clinical context and quality of clinical documentation in the medical record.
Medical necessity establishes the foundation for evaluation and management (E/M) code selection and supports the need to services provided to the patient. Peggy Stilley, CPC, CPMA, CPC-I, COBGC, ACS-OB , and Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, AHIMA-approved ICD-10-CM/PCS trainer, explain how to define, determine, and defend medical necessity for E/M codes.
At first glance, codes for insertion, removal, and revision of pacemakers look quite different in ICD-10-PCS. Kimberly J. Carr, RHIT, CCS, CDIP, and Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, compare and contrast pacemaker procedure coding in ICD-9-CM and ICD-10-PCS.
The AMA significantly changed how coders report cervicocerebral imaging in 2013. Andrea Clark, RHIA, CCS, CPC-H, and David Zielske, MD, CIRCC, CPC?H, CCC, CCS, RCC, discuss the changes and provide tips for coding these services.
Eight CPT ® codes for multianalyte assays with algorithmic analyses (MAAA) procedures are now classified as not covered under OPPS (status indicator E), retroactive to January 1, 2013. These codes are now subject to I/OCE edit 9.
It took some time to break down the wall between coders and CDI specialists at New Hanover Regional Medical Center in Wilmington, N.C. However, that wall eventually crumbled. Linda Rhodes, RN, BSN, CCDS, manager of CDI, says an increased emphasis on communication and respect is what did the trick.
CMS and the Office of the National Coordinator for Health Information Technology recently hosted a listening session to gather industry feedback and concerns about health information technology adoption. Read some of the highlights of the session and comments from providers in the field.
