The AHA's Coding Clinic for ICD-10-CM/PCS , Third Quarter 2015, opens with a discussion of the differences between excisional and non-excisional debridement-diagnoses with a long history of coding and clinical documentation confusion, explains Sharme Brodie, RN, CCDS.
Q: Our physicians sign off on diagnoses that the nursing staff prepares on admission of a new patient, can you suggest a process to capture all relevant diagnoses?
According to the American Hospital Association’s 2015 fourth quarter RACTrac survey, the most commonly cited reason for a Recovery Auditor’s complex claim denial is due to an inpatient coding error.
Cyndi Pickney, DO, FACP explains that as ICD-10 implementation approached last year, organizations reported varying levels of readiness and understanding of the impact on physician workflow, and now, there are unforeseen consequences.
A recent Association of Clinical Documentation Improvement Specialists poll says that 53% of respondents are not experiencing any real problems with ICD-10-CM/PCS, but coding experts have identified a few tricky diagnoses for coders to be aware of.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , and AHIMA-approved ICD-10-CM/PCS trainer, writes that reporting imaging, nuclear medicine, and radiation therapy procedures will dramatically change depending upon whether the patient has been admitted into a hospital or is being cared for as an outpatient
Q: When a foreign body is removed from the eye, does it matter what instrumentation is used to remove it? We recently had two cases in which the ED physician stated that the foreign body was easily removed with a cotton swab. She is questioning whether we should charge (facility and professional) for this type of removal or whether it should just be considered when determining the E/M level.
The Zika virus has become a major concern over the last couple months and new information about treatment and symptoms seems to emerge daily. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the latest information regarding the Zika virus and how coders can report it.
Reporting modifier –PO (services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments) only recently became mandatory, but new rules and regulations could change the requirements in certain settings. Kimberly Anderwood Hoy Baker, JD, CPC, reviews recent legislation that could have an impact on modifier –PO and looks ahead to when CMS intends to offer more guidance.
Drug administration services follow a hierarchy for reporting, but coding can become complex when providers administer multiple drugs. Review these tips to help tackle tough injection and infusion scenarios.
