Hospital inpatient

When a provider notes a diagnosis on the hospital-acquired condition (HAC) list, coders must be diligent about looking throughout the rest of the chart to ensure documentation clearly indicates the presence of a HAC. For example, if the condition is a pressure ulcer, the condition may have been present on admission. Shelia Bullock, RN, BSN, MBA, CCM, CCDS, and Beverly Cunningham, MS, RN, address the importance of coder participation as members of hospital HAC committees and the development of best practices to ensure accurate HAC and HCAC reporting.

Sharme Brodie, RN, CCDS, details some of the top questions and answers from Coding Clinic , Fourth Quarter, 2014.

Physicians use a lot of shortcuts and abbreviations. Some of them may even make it to the official abbreviation list at a hospital. Some don't. Even if they do, some physicians will use the wrong term.

Q: How often should hospital inpatient coding audits be performed?

The goals of coding should always be ensuring data accuracy and capturing a patient's true clinical picture. Knowing the intent of an ICD-9-CM code is crucial. However, coding guidelines and official coding guidance sometimes conflict with these goals, putting coders between a rock and a hard place. Robert S. Gold, MD, examines cardiomyopathy, a disease that affects the heart muscle, as an example of a diagnosis that is frequently misreported due to inaccurate guidance.

ICD-10-PCS will change the way coders count sites for coronary artery bypass graft (CABG) procedures. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Nena Scott, MS, RHIA, CCS, CCS-P, explain how coders will report CABG in ICD-10-PCS.

Q: Can CDI programs use the information on ambulance forms or trip tickets to abstract from if the information is pulled into or reiterated in the ED or history and physical (H&P) documentation? Our staff doesn’t want to miss criteria that would diminish our ability to substantiate the true severity of illness of some patients, but I have been informed that coders are not allowed to code from ambulance papers or information.

CMS continued its focus on improving the quality of patient care in the fiscal year (FY) 2016 IPPS final rule, released July 31.

QUESTION: Do you predict coder productivity will decline as a result of ICD-10? If so, what do you think the declines will be six months after implementation?

Q: If a surgeon removes the appendix at the same time he or she removes the ascending colon, which root operation(s) should we use?