If coders choose the wrong root operation in ICD-10-PCS, they will arrive at an incorrect code. Nena Scott, MSEd, RHIA, CCS, CCS-P, AHIMA-approved ICD-10-CM/PCS trainer, Gretchen Young-Charles, RHIA, Anita Rapier, RHIT, CCS, and Nelly Leon-Chisen, RHIA, discuss some of the root operation clarifications offered by Coding Clinic .
Depending on the demographics of the region a hospital serves, its coders could determine code assignment for hundreds of deliveries and pregnancy-related services annually — reviewing coding guidelines is helpful.
The OIG is taking a closer look at mechanical ventilation, according to its FY 2013 Work Plan. William E. Haik, MD, FCCP, CDIP, and Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, explain why your facility should do the same.
New clinical guidelines for malnutrition could help alleviate compliance challenges associated with coding the condition, which has never had universally accepted clinical criteria. Jane White, James S. Kennedy, MD, CCS, CDIP, and Alice Zentner, RHIA, describe the new guidelines and what coders need to know about malnutrition coding.
ICD-10-PCS differs significantly from ICD-9-CM procedure coding, but fortunately, the Cooperating Parties are providing plenty of guidelines. Laura Legg, RHIT, CCS, discusses some of the key ICD-10-PCS guidelines and why coders should learn them.
Q: ICD-9-CM includes Pott’s fracture as an alternate term for a bimalleolar fracture. However, ICD-10-CM doesn’t include that term in either the Alphabetic Index or the Tabular List. If the physician documents a Pott’s fracture, can we automatically use the code for bimalleolar fractures in ICD-10-CM, even though the term is not in the index?
CMS’ 2015 IPPS proposed rule , released April 30, focuses on quality measures, such as the hospital-acquired condition (HAC) reduction, readmissions reduction, and hospital value-based purchasing and hospital readmissions reduction programs.
In some cases, coding professionals can—and should—report ancillary services provided to inpatients. Denise Williams, RN, CPC-H, and Valerie A. Rinkle, MPA, explain when and how to bill for ancillary bedside services.
Q: A patient came to the ED with shortness of breath (SOB). The admitting diagnosis was possible acute coronary syndrome (ACS) due to SOB and elevated troponin levels. The ACS was ruled out. Elevated troponin levels were assumed to be due to chronic renal failure (CRF), and no reason was given for SOB. Before discharge, the patient was noted with an elevated temperature and found to have a urinary tract infection (UTI). All treatment was directed at the UTI, and the doctor noted the discharge diagnosis as the UTI. What would be the principal diagnosis in this case?
Facilities may be reluctant to charge for bedside services beyond the room rate because they fear double-dipping. Kimberly Anderwood Hoy, JC, CPC, and William L. Malm, ND, RN, CMAS, discuss what CMS does—and doesn’t—say about charging for ancillary services .
