The recent adoption of a refined version of the Patient Safety Indicator (PSI) 90 composite by the Agency forHealthcare Research and Quality (AHRQ) has a significant impact on what discharges are included in PSI 15 (Unrecognized Abdominopelvic Accidental Puncture Laceration Rate).
The new guideline for code assignment and clinical criteria in the 2017 ICD-10-CM Official Guidelines for Coding and Reporting does not mean clinical documentation improvement is going away; instead it just upped the ante for continued improvement.
With only 60 days between the OPPS final rule's release and the January 1 implementation date, providers will be ahead of the curve by spending time now and thinking about the processes they may need to review, change, or implement based on what CMS finalizes and the sort of financial impact the final rule is likely to have.
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?
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.
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.
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.
In early August, hospitals got a last-minute reprieve from the Medicare Outpatient Observation Notice (MOON) notification requirement. CMS detailed the need for additional time to revise the standardized notification form that hospitals will need to use to notify patients about the financial implications of being assigned to observation services; and, as of now, the requirement is still in delay.
With all the hoopla over sepsis, pressure ulcers, and diabetes coding, there’s a little gem of coding advice that has been overlooked since ICD-10 was released: pneumonia and chronic obstructive pulmonary disease. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , writes about these changes and helps to decipher the new guideline changes. Note: To access this free article, make sure you first register for the free content if you do not have a paid subscription.
