CMS proposed a major change to physician certification requirements in the 2015 OPPS proposed rule. Kimberly A.H. Baker, JD and James S. Kennedy, MD, CCS, CDIP, break down how the change could affect inpatient admissions.
As you may know, ICD-9-CM V codes have been expanded to include higher body mass indexes (BMI). More specifically, code category V85.4x denotes a BMI of 40 or more in an adult. How can you calculate BMI?
All pressure ulcers are wounds, but not all wounds are pressure ulcers. A wound is an injury to living tissue caused by a cut, blow, or other external or internal factor. Wounds usually break or cut the skin.
Every few years, the AHA publishes guidance in Coding Clinic that can significantly affect inpatient coders, such as guidance published in the Second Quarter 2012 on neoplasm coding. Randy Wagner, BSN, RN, CCS, and Paul Dickson, MD, CCS, CPC, review the new guidance and how to use the TNM cancer staging system.
Q: A patient presents with altered mental status/encephalopathy due to a urinary tract infection (UTI). The patient has a history of dementia. The final diagnosis is encephalopathy due to UTI. Should we code the encephalopathy as a secondary diagnosis because it’s an MCC and not always a symptom of a UTI?
Patient Safety Indicator 90 evaluates hospital performance for defined in-hospital complications and adverse events. Find out more about how clinical documentation and coding can affect this measure in the first of a four-part series.
Q: We have a problem getting our physicians to understand what we are querying for chronic respiratory failure when a patient is on home oxygen continuously with documented supplementary oxygen of less than 90%, or arterial blood gas with hypoxemia. The physicians tell us chronic obstructive pulmonary disease (COPD) is chronic respiratory failure by definition. Can you help us clarify this situation or give us some tips on how to educate our physicians?
QUESTION: I have a question regarding the coding of a computer-assisted fluoroscopy. Consider the following documentation: Use and interpretation of intraoperative fluoroscopy. After positioning the patient, the posterior lumbar area was prepped and draped in the standard sterile fashion. The prior incision was marked with a marking pen. C-arm fluoroscopy was used to map an incision extending from the tip of the spinous process of L2 to that of L5. After performing a time-out, this incision was infiltrated with local anesthetic and incised with a 10-blade scalpel. Dissection proceeded through the subcutaneous fat using Bovie monopolar cautery. Self-retaining retractors were applied. Dissection then proceeded in the midline through the avascular plane through the lumbodorsal fascia and musculature using the Bovie. Self-retaining retractors were deepened. Would you assign a procedure code for the fluoroscopy for this inpatient procedure or would it just be inclusive in the procedure? There seems to be confusion when comparing this procedure in an inpatient setting vs. an outpatient setting.
