Physicians can biopsy numerous body sites and structures, including muscles, organs, and fluids. Mark N. Dominesey, MBA, RN, CCDS, CDIP, and Nena Scott, MSEd, RHIA, CCS, CCS-P, dig into biopsy coding in both ICD-9-CM and ICD-10-CM.
Inpatient coding professionals are used to DRG systems where all of the diagnoses and procedures map to a single DRG. So they may not look for additional procedures and services to report outside of that DRG.
Q: In ICD-9-CM, sprains and strains fall under the same codes. Will that also be the case in ICD-10-CM or are we going to report these injuries separately?
When a physician closes off varices, coders must determine the location and method the physician used to correctly build an ICD-10-PCS code. Nena Scott, MSEd, RHIA, CCS, CCS-P, and Gretchen Young-Charles, RHIA, review the components of different procedures for closing off varices and how to code those procedures in ICD-10-PCS.
Q: How would the following be viewed if it was included in a cardiology consult note: Mr. Jones has paroxysmal atrial fibrillation. He had a recurrence last night which was asymptomatic. We think this happens all the time at home. This is not a pacing post-conditioning (PPC). He is back in normal sinus rhythm (NSR). I would restart his warfarin if Dr. Smith will allow. Goal International Normalized Ratio (INR) is 2-3.
The 2015 IPPS final rule focused on quality measures. James S. Kennedy, MD, CCS, CDIP, and Cheryl Ericson, MS, RN, CCDS, CDI-P, highlight the changes and explain the role of coding in quality scores.
Problems can occur anywhere along the alimentary canal or in any of the accessory organs. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, discusses some common diagnosis and procedure codes for digestive diseases and procedures.
CMS designates a certain set of procedures as inpatient-only, meaning it will only reimburse facilities for these procedures when they are performed in the inpatient setting. Inpatient-only procedures present numerous problems for hospitals.