Breast biopsies should be easy to code because coders have so few codes to assign, but it is one area where documentation is lacking. Stacie L. Buck, RHIA, CCS-P, RCC, CIC, reveals what key elements coders should look for in a breast biopsy note.
Editor's note: Facilities need to address coding, payment, and coverage issues for molecular pathology. This article is the first in a series and discusses molecular pathology coding.
In the coding world, it’s a never-ending clash that can cause compliance concerns—facility vs. professional. Kimberly Anderwood Hoy, JD, CPC , and Peggy Blue, MPH, CPC, CCS-P, explain how coders in each setting use different codes for the exact same services based on the payment systems, the rules, and how each setting applies those rules.
Recovery Auditors are currently performing prepayment MS-DRG validation and coding reviews of MS-DRG 312 (syncope and collapse). Ralph Wuebker, MD, MBA, and Stacey Levitt, RN, MSN, CPC, discuss the scope of the new reviews and what coders need to look for in documentation of syncope.
If you think you’ve estimated the right amount of training time for ICD-10-CM, you probably should increase it. Cindy Grant, CHIM , Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, and Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, explain why organizations will need to plan additional hours of training for ICD-10-CM.
Researcher Bill Rudman, PhD, RHIA, says he didn't fully understand the implications of codes that coders assign until he was sitting around a table with several criminal justice officials who said that coded data helps reduce violent crimes and recidivism.
The AMA added five new nuclear medicine codes to the radiology section of the 2013 CPT Manual , while revising and deleting a number of codes that represented outdated technology or were bundled into placement procedures.
Physician documentation must reflect severity of illness and risk of mortality for all patients. Robert S. Gold, MD, and Valerie Bica, BSN, RN, CPN, explain why pediatric patients require special attention in terms of clinical documentation improvement specialists.
Genetic screening is often used to detect abnormal genes or possible fetal anomalies during antepartum care. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, reviews some of the most common genetic tests and what diagnosis codes to report.
MS-DRGs won’t change much in the first year after the transition to ICD-10, but hospitals still need to understand the details of the transition. Janice Bonazelli and Dwan Thomas Flowers, MBA, RHIA, CCS, explain how to use the draft ICD-10 MS-DRG Definitions Manual to prepare for MS-DRGs in ICD-10.
