The HIM profession is constantly changing, but HIM professionals are still responsible for maintaining the integrity of the health records. Lou Ann Wiedemann, MS, RHIA, FAHIMA, CPEHR, explains why HIM professionals can—and should—also play a role in clinical documentation improvement (CDI).
Inpatient-only procedures are those that CMS has determined providers must perform on an inpatient basis. Kimberly Anderwood Hoy, JD, CPC, and Beverly Cunningham, MS, RN, unravel the complexities of coding for these procedures.
Provider documentation of inpatient wound care services may be confusing at best and completely lacking at worst. Coders end up trying to decipher exactly what procedure the provider performed. Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, and Robert S. Gold, MD, offer tips to assist coders in choosing the correct code for inpatient wound care.
The OIG estimates that Medicare Administrative Contractors paid $8.4 million in overpayments to inpatient rehabilitation facilities (IRFs) because IRF and Medicare payment controls did not adequately identify late submissions of patient assessment instruments.
Q: I have a question about coding transplant complications. My understanding is if the complication affects the transplanted organ, then coders should assign a code for the transplant complication itself. Is this correct? Consider the following physician documentation: Final A/P: Acute renal failure in patient with history of renal transplant. Should coders report 996.81 (complications of transplanted kidney) and 584.9 (acute kidney failure, unspecified)? Also consider this documentation: CHF in heart transplant patient . Should coders report 996.83 (complications of transplanted heart) and 428.0 (CHF, unspecified)?
