Emergency departments (ED) at designated trauma centers encounter some of the most complex patients—and with them, a complicated documentation web that’s difficult for even the most experienced CDI specialists and coders to untangle.
Greek philosopher Heraclitus once said the only constant is change. With the release of the fiscal year (FY) 2019 IPPS proposed rule , and all of the changes it contains, CMS has certainly proven Heraclitus correct. The rule applies to 3,257 acute care hospitals, and once finalized, will affect discharges on or after October 1.
In inpatient coding, all diagnoses that affect the current hospital stay must be reported. In addition, the Uniform Hospital Discharge Data Set is commonly followed for reporting secondary diagnoses; it says that other (or additional) diagnoses are defined as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay."
When building a successful proactive clinical documentation approach, the effort of setting up communication dynamics is essential and should certainly be a priority.
Just like their inpatient acute care counterparts, inpatient psychiatric facilities use ICD-10-CM codes, but their payment structure, documentation requirements, prevalent clinical conditions, and additional documentation requirements needing capture are vastly different.
James S. Kennedy, MD, CCS, CDIP, CCDS , writes that ICD-10-CM/PCS documentation and coding rules surrounding patient safety indicators (PSI) must be honored in order to ensure proper compliance and reimbursement.
According to the National Institute of Health, approximately 100,000 Americans have sickle-cell disease. In this article, Peggy Blue, MPH, CCS, CCS-P, CPC, CEMC , breaks down the complexities of the disease and clarifies reporting of the diagnosis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Allen Frady, RN-BSN, CCDS, CCS, CRC, reviews proposed changes applicable to coding and CDI teams within the fiscal year (FY) 2019 IPPS proposed rule including HIV disease, ARDS, and CC/MCC changes.
A common question that coders often ask is when to report a secondary diagnosis. In part two of this two-part series, Gloryanne Bryant, RHIA, CDIP, CCS, CCDS , looks at the chapter-specific coding guidelines related to secondary diagnosis coding found in the ICD-10-CM Official Guidelines for Coding and Reporting.
