Editor's note: With the increased specificity required for ICD-10-CM coding, coders need a solid foundation in anatomy and physiology. To help coders prepare for the upcoming transition, we will provide occasional articles about specific anatomical locations and body parts as part of a larger series for ICD-10-CM preparation. This month's article addresses the anatomy of the urinary system.
The American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS) released joint physician query instructions in Guidelines for Achieving a Compliant Query Practice in February 2013.
Coders and clinical documentation improvement specialists often focus on different information when reviewing documentation for heart disease. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Cheryl Ericson, MS, RN, CCDS, CDIP, highlight the different perspectives.
Debbie Mackaman, RHIA, CPCO, CCDS, discusses modifier -59 (distinct procedural service) use, including the latest guidance from CMS on the four new, more specific replacements—and how more guidance is needed before providers can feel comfortable using them.
The ICD-10-PCS Manual includes 17 different sections, including Administration. Learn how to assign codes from this section to prepare for ICD-10-PCS implementation.
The AMA added a new CPT ® code for chronic care management. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, writes about the time and documentation requirements for reporting this service.
Since portions of the reproductive system use some of the same structures as the urinary system, including the urethra, codes for conditions involving both male and female reproductive systems appear in Chapter 14 of ICD-10-CM, Diseases of the Genitourinary System.
Coding tells a patient's story, based on the narrative the physician provides in his or her documentation. Accurately painting a picture of the patient's severity of illness (SOI) and risk of mortality (ROM) is essential for good patient care, and it is becoming increasingly important for quality measures and payment.
Accurately painting a picture of the patient's severity of illness (SOI) and risk of mortality (ROM) is essential for good patient care, and it is becoming increasingly important for quality measures and reimbursement. Sara Baine, MSN-Ed, CCDS, and Rhonda Peppers, RN, BS, CCDS , explain the importance of accurately reporting conditions that affect SOI and ROM.
Blood tests are a common diagnostic tool for providers trying to determine a patient's condition. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, reviews the components of blood, detailing key terms and conditions coders should know to prepare for ICD-10-CM.
