The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)¹ as published on February 23 in the Journal of the American Medical Association represents a radical departure from the prior sepsis definitions in 1991² (identified as Sepsis-1) and 2001³ (identified as Sepsis-2) and subsequent Surviving Sepsis Campaign (SSC) guidelines through 2015.
There have been some significant changes in documentation needs for diseases of the brain since October 2015. These can affect accurate patient data as well as providing information for the treatment needs of the patients both during a hospital stay and afterwards. They will enable patient information to be available to all providers and ensure that you get paid appropriately for the complexity of the patients under your care.
In February 2016, just four months after ICD-10 go-live, sister publication HIM Briefings (formerly Medical Records Briefing ) asked a range of healthcare professionals to weigh in on their productivity in ICD-9 versus ICD-10.
Under the CJR, which began April 1, acute care hospitals in selected geographic areas assume quality and payment accountability for retrospectively calculated bundled payments for lower extremity joint replacement (LEJR) episodes. Episodes begin with admission to an acute care hospital for an LEJR procedure that is paid under the IPPS through MS-DRGs 469 or 470 (Major joint replacement or reattachment of lower extremity with or without MCC, respectively) and end 90 days after the date of discharge from the hospital.
The new modifier -PO (services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments [PBD]) and the alternative payment provisions under the Bipartisan Budget Act Section 603 are both related to off-campus PBDs but define "off-campus PBD" slightly differently.
Providers need to keep more in mind than just diagnosis and procedure coding when performing sterilizations for men and women. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, reviews the requirements for sterilizations and the part coders can play in avoiding denials.
Respondents to HCPro’s 2016 ICD-10 survey share their challenges and successes since implementation, while Monica Pappas, RHIA, and Darice M. Grzybowski, MA, RHIA, FAHIMA, offer their thoughts on the impact of ICD-10.
Q: What is the proper ICD-10-CM coding for bilateral hip pain? Should we report M25.551 (pain in right hip) and M25.552 (pain in left hip) or M25.559 (pain in unspecified hip)?
The Centers for Disease Control and Prevention released new guidance last week with updated clinical recommendations for patients exposed to the Zika virus and also announced a registry for pregnant women infected with the virus.
ICD-10 implementation represented an unprecedented challenge for the U.S. healthcare system. Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, writes about the impact of the change by looking at survey results that compare ICD-10 productivity benchmarks to ICD-9-CM.
Q: Can you clarify the expectations related to documenting the discussion between a physician and a clinical documentation improvement specialist when a query is done verbally? The 2013 ACDIS/AHIMA physician query practice brief Guidelines for Achieving a Compliant Query Practice expanded on the need to document this interaction and we’re wondering if our process is compliant.
On March 9 and 10, CMS held the ICD-10 Coordination and Maintenance Committee meeting to discuss approving changes, additions, and other modifications to the ICD-10 code set.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, writes about key details in documentation that coders will need to look for in order to report procedures using the root operation Dilation.
Barbara A. Anderson, RN, MSM, says that in 2014, 66% of 318 hospitals surveyed by AHIMA had a CDI program in place. Anderson explains how CDI programs can be a valuable bridge between clinical care and coding at hospitals, and gives examples on how to improve upon a facility’s program.
The AHA's Coding Clinic for ICD-10-CM/PCS , Third Quarter 2015, opens with a discussion of the differences between excisional and non-excisional debridement-diagnoses with a long history of coding and clinical documentation confusion, explains Sharme Brodie, RN, CCDS.
A recent Association of Clinical Documentation Improvement Specialists poll says that 53% of respondents are not experiencing any real problems with ICD-10-CM/PCS, but coding experts have identified a few tricky diagnoses for coders to be aware of.
Q: Our physicians sign off on diagnoses that the nursing staff prepares on admission of a new patient, can you suggest a process to capture all relevant diagnoses?
