What do cubism and coding have in common? Both can be viewed as art forms. Joel Moorhead, MD, PhD, CPC, details the three steps that the coding artist performs in reassembling medical record elements into abstracted form.
There is nothing new about stress; humans have felt stress since the beginning of time, and coders are certainly no exception. Lois Mazza, CPC, discusses how coders can mitigate the many effects of stress while they handle the pressures of their jobs and lives.
New clinical guidelines for malnutrition could help alleviate compliance challenges associated with coding the condition, which has never had universally accepted clinical criteria. Jane White, James S. Kennedy, MD, CCS, CDIP, and Alice Zentner, RHIA, describe the new guidelines and what coders need to know about malnutrition coding.
A lot of learning is ahead for coders and others who will need to learn how to code in ICD-10. There are changes all around, and OB coding is no exception. Lori-Lynne A, Webb, COBGC, CPC, CCS-P, CCP, CHDA, explains coding for OB ultrasounds, amniocentesis, MRIs, and other procedures in CPT ® , ICD-9, and ICD-10
Many physicians say that systemic inflammatory response syndrome (SIRS) criteria are insufficient and confusing at best, and don't indicate whether a patient is truly sick. Some patients may meet necessary criteria for SIRS and truly have sepsis or another severe diagnosis. Others, however, may meet two of four criteria but not actually have SIRS. Where does all of this information leave coders? Often between a rock and hard place. Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, and Robert S. Gold, MD, offer seven tips for coders who need to negotiate tricky sepsis coding.
While we know the implementation date of ICD-10 may change to the proposed 2014 deadline, healthcare organizations must keep moving forward with preparations. Annie Boynton, BS, RHIT, CPC, CCS, CPC-H, CCS-P, CPC-P, CPC-I, CPhT, explains how organizations can use the additional time to better handle the change process associated with ICD-10, especially planning for education and training.
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.
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.
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).