Drug-resistant bugs are becoming more common as antibiotic use increases. Shelley C. Safian, PhD, CPC-H, CPC-I, CCS-P , AHIMA-approved ICD-10-CM/PCS trainer, explains why and how microbes become antibiotic resistant and compares ICD-9-CM and ICD-10-CM coding for these infections.
Skin and dermatology coding includes unique challenges with its extensive terminology and the need to calculate wound and lesion sizes. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , discusses common documentation problems and how coders can improve their efficiency and proficiency.
With the added specificity available in ICD-10-CM, coders have many more options for reporting malignancies of the skin. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I , compares ICD-9-CM codes with their ICD-10-CM counterparts and notes where more documentation may be needed to select the proper code.
In ICD-10-PCS, coders will need to find details they currently don’t use. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, offers tips for locating the necessary information in the body of the operative report.
In order to report accurate evaluation and management codes, coders need accurate, complete documentation. Coders can play a critical role in ensuring proper documentation. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, looks at methods coders can use to promote better documentation.
Documentation and medical necessity continue to be scrutinized by payers and auditors. Debbie Mackaman, RHIA, CPCO, and Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, explain how complete, accurate documentation of the entire patient encounter justifies the physician’s decision to admit.
Physicians are never going to like receiving queries from coders and CDI specialists. They really won't like all the queries they will receive after the transition to ICD-10.
Coding for acute and chronic pain will not change greatly in ICD-10-CM, though coders will have some new options at their disposal. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I , discusses some common pain diagnoses and how they will translate from ICD-9-CM.
Clinical queries serve a definitive purpose when documentation in the medical record is ambiguous, inconsistent, lacking specificity, or contradictory. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, explains why documentation improvement initiatives and heightened coder awareness of the need to query can be an asset or liability.