To correctly assign codes for any surgical procedure, coders need to have an operative (OP) report. But simply having an OP report isn’t enough. Coders also must be able to read the OP report and pick out the important information. Lynn Pegram, CPC, CEMC,CPC-I, CGSC, breaks down the OP report to help coders find the information they need.
Peggy Blue, MPH, CPC, CCS-P, CEMC, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, review code changes in the 2015 CPT® Manual's Medicine section, including newly available products and services.
More than 330 codes have been added, deleted, or revised in the 2014 CPT ® Manual . Almost one quarter of those changes appear in the digestive system. Joanne Schade-Boyce, BSDH, MS, CPC, ACS , notes important code and guideline changes to be aware of for 2014.
While the 2014 CPT ® Manual features many new combination codes among its hundreds of changes this year, it was also updated to reflect newly recognized technologies and procedures . Denise Williams, RN, CPC-H, looks atsome of the changes made in the Radiology and Laboratory sections.
As the role of radiologists has expanded to new procedures, so have the codes to report their work in the CPT ® Manual . Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, writes about key terms for coders to look for in documentation to correctly report these procedures.
After years of consideration, CMS introduced extensive changes for modifier -59 (distinct procedural service) for 2015. Jugna Shah, MPH , explains these changes and when to use the new modifiers instead of modifier -59.
The AMA added a total of 60 new codes throughout the surgery section of the 2012 CPT ® Manual , 18 of which appear in the cardiovascular and respiratory system subsections. The AMA also revised 86 codes and deleted 48 codes in the surgery section. Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, and Christi Sarasin, CCS, CCDS, CPC-H, FCS, highlight the significant changes for 2012.
Evaluation and management (E/M) coding is incredibly subjective. Two coders can look at the same documentation and choose two different E/M levels and both will be able to justify their choice. Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, AHIMA-Approved ICD-10-CM/PCS Trainer , Lori Owens, RHIT, CCS, and Deborah Robb, BSHA, CPC, discuss how electronic medical records can complicate E/M coding even more.
To code chemotherapy properly, coders need to understand what the clinical staff actually does for the patient via complete and accurate documentation. Chemotherapy and other injections and infusion present some unique challenges in part because clinical staff members are focused more on patient care than documentation requirements. Paula Lewis-Patterson, BSN, MSN, NEA-BC, and Jugna Shah, MPH, discuss the challenges of compiling complete chemotherapy documentation.
