Coders and clinicians seem to speak different languages. CDI specialists often serve as the translators between clinicians and coders, so it's important that all three groups work together.
ICD-10-CM is similar to ICD-9-CM, but coders need to watch out for differences which could lead to incorrect coding. Nelly Leon-Chisen, RHIA, Gretchen Young-Charles, RHIA, and Sarah A. Serling, CPC, CPC-H, CPC-I, CEMC, CCS-P, CCS , discuss possible pitfalls for coding myocardial infarctions, neoplasms, and external causes in ICD-10-CM.
Inpatient-only procedures are those that CMS has determined providers must perform on an inpatient basis. Kimberly Anderwood Hoy, JD, CPC, and Beverly Cunningham, MS, RN, unravel the complexities of coding for these procedures.
CMS proposed that a new HCPCS modifier be appended to every code for a service furnished in a hospital's off-campus provider-based department on both the CMS-1500 claim form for physicians' services and the UB-04 form (CMS Form 1450) for hospital outpatient services in the 2015 OPPS proposed rule. Despite many detailed comments opposing this change, no consensus emerged; therefore, CMS is moving forward with implementing a slightly modified policy.
Q: We know that we can look at the radiology report to get some specifics about a fracture. When it comes to an open fracture in ICD-10-CM, can you determine the Gustilo-Anderson classification, whether it's I, II, IIIA, IIIB, or IIIC, based on a description of the wound? Or does the physician actually have to document, “It's a Gustilo type I" or "type III”?
Cheryl Ericson, MS, RN, CCDS, CDIP, discusses the difference between “after study” and “due to” when it comes to choosing the correct principal diagnosis .
Q: How specific does the physician have to be for the location of the acute myocardial infarction (MI) in ICD-10-CM? We don’t do catheterizations at my facility .
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?
