Computer-assisted coding (CAC) is a hot topic these days. Many industry experts claim that CAC is the wave of the future—that its accuracy has been proven, and that humans cannot match its productivity. With CAC, elements such as fatigue, stress, and inexperience are no longer factors that can negatively affect code assignment. Many articles and vendors sing its praises. However, is it really all that? Robert S. Gold, MD, and Lori Cushing, RHIT, CCS, discuss some relevant concepts.
Times are changing, and, most likely, so are the jobs of your health information management (HIM) staff members. In some cases, there's a sudden addition of responsibilities, such as the implementation of the recovery audit contractor program. In other cases, the increased use of technology triggers a shift. If these changes aren't managed appropriately, you may end up with declines in performance, careless errors, low productivity, or diminished quality. Elizabeth Layman, PhD, RHIA, CCS, FAHIMA, shares her approach to HIM department and job restructuring.
The goals of coding should always be ensuring data accuracy and capturing a patient's true clinical picture. Knowing the intent of an ICD-9-CM code is crucial. However, coding guidelines and official coding guidance sometimes conflict with these goals, putting coders between a rock and a hard place. Robert S. Gold, MD, examines cardiomyopathy, a disease that affects the heart muscle, as an example of a diagnosis that is frequently misreported due to inaccurate guidance.
The Office of the Inspector General (OIG) stated in its recent publication, “Hospital Incident Reporting Systems Do Not Capture Most Patient Harm,” that a series of reports examining adverse events in hospitals shows that for the hospitals it surveyed, the incident reporting systems only tracked approximately 14% of incidents.
QUESTION: I have a question regarding the coding of a computer-assisted fluoroscopy. Consider the following documentation: Use and interpretation of intraoperative fluoroscopy. After positioning the patient, the posterior lumbar area was prepped and draped in the standard sterile fashion. The prior incision was marked with a marking pen. C-arm fluoroscopy was used to map an incision extending from the tip of the spinous process of L2 to that of L5. After performing a time-out, this incision was infiltrated with local anesthetic and incised with a 10-blade scalpel. Dissection proceeded through the subcutaneous fat using Bovie monopolar cautery. Self-retaining retractors were applied. Dissection then proceeded in the midline through the avascular plane through the lumbodorsal fascia and musculature using the Bovie. Self-retaining retractors were deepened. Would you assign a procedure code for the fluoroscopy for this inpatient procedure or would it just be inclusive in the procedure? There seems to be confusion when comparing this procedure in an inpatient setting vs. an outpatient setting.