Coders should question the validity of coding advice and work collaboratively with physicians to develop sound coding guidelines. Last month, I addressed coding advice related to percutaneous endoscopic gastrojejunostomy and cardiorenal syndrome. This month, I’ll address coding advice related to several other conditions.
CMS' introduction of the 2-midnight rule in the 2014 IPPS final rule makes properly identifying inpatient-only procedures even more important for hospitals.
Physicians, especially ED physicians, need to start paying attention to how their documentation affects the facility. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, and Bernadette Larson, CPMA, discuss how documentation in the ED affects medical necessity and inpatient coding.
Spinal fusion is a procedure to join, or fuse, two or more vertebrae and can be performed in both the inpatient and outpatient settings. Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, MCP, review spinal anatomy before discussing correct ICD-9-CM Vol. 3 and ICD-10-PCS coding for inpatient spinal fusions.
Clinical auditors are often not able to translate from ICD-9 to CPT ® to determine a procedure is inpatient-only, which leads to denials. Kimberly A.H. Baker, JD, CPC, and Beverly Cunningham, MS, RN, reveal common causes of denials and what hospitals can do to overturn incorrect denials.
QUESTION: Can a patient have encephalopathy after surgery? For example, a patient becomes confused post-surgery and is transferred from the medical-surgical floor to the intensive care unit, where he or she receives high doses of pain medication via IV. However, the patient recovers well and the confusion disappears after the IV fluids and reduction in pain medication and oxygen. Would it be appropriate to query the physician regarding encephalopathy and its possible cause, or would this be a red flag for auditors? The situation did extend the patient’s length of stay by one day.
Q: Which ICD-10-CM external cause code should we report if a patient falls while on an escalator? This is the first time that the patient has been seen for such a fall.
