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.
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.
Trey La Charité, MD , writes about how he feels the days of merely maintaining compliance with published coding guidelines are gone, and suggests ways to protect a facility and appeal audits.
Q: What is the correct procedure code for an esophagogastroduodenoscopy? Our coder coded 0DQ68ZZ (Repair, stomach, via natural or artificial opening, endoscopic), which groups to DRG 326, the same as an esophagectomy. The relative weight is 5.45. This does not seem right. Could you please clarify?
This October celebrates the eight month anniversary of the February release of the controversial third international consensus definitions for sepsis and septic shock. James S. Kennedy, MD, CCS, CDIP , tackles this new sepsis definition in part one of his two-part series.
More than half of the members of Congress have written to CMS to consider changes to its proposals for implementation of Section 603 of the Bipartisan Budget Act of 2015 regarding off-campus, provider-based departments.
Human papillomavirus is the most common sexually transmitted infection in the U.S. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, reviews how to report vaccinations for the virus and how coverage policies by differ by carrier. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Once you have set up your free registration, you can log in and access this article by clicking here.
