Knowing when and how to query for all conditions is crucial; this couldn't be truer for CCs and MCCs, conditions that affect payment and help capture a patient's true clinical picture and complexity.
Q: As a traveling consultant, I review many types of inpatient hospital records. As hospitals have implemented electronic health records (EHR), I’ve seen documentation worsen. The ability to cut and paste information in the record has compromised coding accuracy. It has also increased the volume of queries, which frustrates physicians. For example, a physician performs a history and physical (H&P) in his or her office one week prior to admitting a patient to the hospital. The first progress note in the EHR—as well as each subsequent progress note—includes the exact same documentation. This documentation, which continues for four days while the patient is in the hospital, is clearly based on the original H&P. Obviously, the documentation has been copied and pasted from one note to another. Even the patient’s vital signs remain exactly the same as they were in the physician’s office. Coders have no way of knowing whether physicians who treat the patient in the hospital agree with any test findings because residents simply cut and paste the results in each subsequent progress note. Residents claim that they do this solely for the attending physician’s convenience. Clinical documentation improvement (CDI) specialists don’t address the problem because they are more focused on determining the accuracy of the MS-DRG. Is there a solution that will keep physicians, coders, and CDI specialists all on the same page?
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-CM will still allow coders to report unspecified codes. However, coders will not have that option in ICD-10-PCS. Every character has to have a value, which will lead to an increase in surgical queries.
CMS designates certain procedures as inpatient-only, meaning it will only reimburse the facility when the procedure is performed on an inpatient. However, CMS identifies these procedures using outpatient CPT ® codes. Beverly Cunningham, MS, RN, and Kimberly A.H. Baker, JD, CPC, discuss the process for identifying and coding inpatient-only procedures.
How does medical necessity get “overlooked” on the physician side as well as the inpatient side? Case managers, utilization review staff, physician advisors, CDI specialists, and coders, each carry out specific duties and responsibilities when reviewing medical records. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS, examines contributing factors and takes a closer look at guidelines Trailblazer Health recently issued defining specific joint replacement (DRG 470) documentation that both hospitals and physicians should follow to support medical necessity.
Q: Can you ask a yes or no question in a query based on clinical information from a previous echocardiogram report or other diagnostic result from a previous admission?
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.
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 .
ICD-10-PCS root operations Control and Repair are used when a procedure doesn’t really fit into a different root operation. Nena Scott, MSEd, RHIA, CCS, CCS-P, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS , discuss when coders should use these two root operations.
