On January 9, CMS announced the launch of Bundled Payments for Care Improvement Advanced from the agency’s Center for Medicare and Medicaid Innovation.
Q: If the attending physician documented, “likely mixed cardiogenic and septic shock,” can I assign ICD-10-CM codes R57.0 (cardiogenic shock) and R65.21 (severe sepsis with septic shock)?
Lynelle A. Clausen, RN, BSN, writes about the struggles she faces as a CDI specialist when dealing with vague documentation, lack of criteria, and the reporting of malnutrition.
Surprisingly, thyroid disease is more common than diabetes or heart disease, with an estimated 20 million Americans having some form of the disease. In this article, Yvette M. DeVay, MHA, CPC, CPMA, CIC, CPC-I gives readers a background on thyroid cancer and reviews ICD-10-CM/PCS coding for the disease.
In perusing the United States Department of Health and Human Services Office of Inspector General’s (OIG) Work Plan , there are many clinical issues that we in ICD-10-CM/PCS coding compliance must address.
Q: Could you discuss or explain evaluating encounter billing vs. monthly billing for recurring outpatient services such as chemotherapy infusions or radiation oncology?
In this article, Valerie A. Rinkle, MPA, offers guidance regarding the 340B drug discount program. She provides tips for accurate documentation of drug purchases and reviews frequently asked questions about billing for 340B-acquired drugs in 2018.
With providers continuing to expand clinical documentation improvement efforts into outpatient settings, ACDIS has published a position paper offering guidance to outpatient CDI departments for performing queries.
Coding for damage control surgery and acute blood loss anemia can be difficult when clear provider documentation is not found within the medical record. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, outlines best practices for identifying anemia and ensuring more accurate documentation.
Complying with healthcare regulations within a coding department or physician practice involves promoting a positive attitude toward activities such as self-monitoring and staying up-to-date with healthcare regulations. Follow these steps to adhere to sound business ethics and set expectations for behavior across an organization. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
While a facility’s case–mix index is an important metric to measure, program managers and directors warn that metrics mean different things to different stakeholders and that CDI programs need to work diligently to present their data within the context of a host of other important measures.
A report released by the American Hospital Association and Manatt Health found that facilities spend approximately $39 million annually to comply with 629 requirements across nine regulatory domains.
Victoria M. Hernandez, RHIA, CDIP, CCS, CCS-P , AHIMA-approved ICD-10-CM/PCS trainer, and Debi Primeau, RHIA, FAHIMA , highlight several areas that illustrate the increasing importance of code specificity to ensure accurate reporting and appropriate reimbursement.
Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, writes about the Office of the Inspector General’s (OIG) recent audit findings regarding the ICD-9-CM diagnosis code for kwashiorkor, and discusses what coders can do to stay compliant when coding guidance is lacking. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: I have a question regarding unilateral weakness from a previous stroke. The patient has ongoing weakness in both right arm and leg post cerebrovascular accident (CVA) and associated ataxia post CVA in 2013. What is the accurate code assignment?
Hospitals are seeing a growing number of staff move off-site. Remote inpatient coders are common and might work from home several days a week. The shift is fueled in part by EHRs: As paper records disappear, it’s less necessary to have staff in nonclinical positions on-site. And, for many hospitals, space is at a premium.
With yearly code and guideline updates to the respiratory system, it’s important for coders to stay abreast of changes to ensure documentation and coding integrity.
CMS' 340B FAQ reviews modifiers -JG (drug or biological acquired with 340B drug pricing program discount) and -TB (drug or biological acquired with 340B drug pricing program discount, reported for informational purposes) and requires 340B hospitals to report modifiers even on drugs that are not subject to the discount policy.
