In this month’s issue, we examine how coders and CDI specialists look at chest pain, review the most recent Coding Clinic advice on ICD-10-PCS , and explain how querying can lead to a more accurate representation of a patient’s severity of illness and risk of mortality. Robert S. Gold, MD, discusses whether coders should report every diagnosis mentioned in a patient’s chart.
Our sister website JustCoding.com recently published its 2014 Coder Salary Survey. Since many of our readers responded to the survey, we would like to share some of the results with you.
Coronary artery disease (CAD) develops when the arteries that supply the blood to the heart muscles become hardened and narrowed due to a buildup of cholesterol and other materials, such as plaque, on their inner wall. It's also called atherosclerosis.
We’re into dig out mode here in Anytown and apparently, not everyone got the memo about proper snow shoveling techniques. Richard came into the Fix ‘Em Up Clinic complaining of intense pain in his...
A hiatus from Recovery Auditor scrutiny may have allowed HIM professionals to focus on other issues, but Laura Legg, RHIT, CCS, explores why HIM departments need to gear up for Recovery Auditors’ return.
Accurately painting a picture of the patient's severity of illness (SOI) and risk of mortality (ROM) is essential for good patient care, and it is becoming increasingly important for quality measures and reimbursement. Sara Baine, MSN-Ed, CCDS, and Rhonda Peppers, RN, BS, CCDS , explain the importance of accurately reporting conditions that affect SOI and ROM.
Physician documentation for the use of osteogenic stimulators for nonunion of fractures is often insufficient for Medicare coverage, according to Comprehensive Error Rate Testing (CERT) results .
In order to identify patients with a CC or MCC, coders need to know when to report additional diagnoses. William E. Haik, MD, FCCP, CDIP, and Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, discuss when to report a secondary diagnosis.
Q: When atelectasis is noted on an ancillary test such as a CT scan of the abdomen or chest x-ray, can nursing documentation of turning, coughing, and deep breathing be considered an intervention that qualifies as one of the criteria to meet a secondary diagnosis?
Here in Anytown we are getting blasted by a big winter storm, which means we’re also seeing lots of patients with storm-related injuries at the Fix ‘Em Up Clinic. Doug came into the clinic...
We can choose from 31 root operations in the ICD-10-PCS Medical and Surgical section, but biopsy isn’t one of them. So which root operation do we use when a physician performs a biopsy? The answer is...
Some diseases can cross between species, which can presents a significant problem. Just think back to how quickly avian flu spread starting in 2003. It turns out that diseases have been crossing that...
ICD-10 implementation requires organizational coordination from a variety of departments. Chloe Phillips, MHA, RHIA, and Kayce Dover, MSHI, RHIA, discuss how organizations can overcome challenges regarding staffing, productivity, and data analytics as they prepare for the change.
Blood tests are a common diagnostic tool for providers trying to determine a patient's condition. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, reviews the components of blood, detailing key terms and conditions coders should know to prepare for ICD-10-CM.
Q: When would we use codes from ICD-10-CM category E13 (other specified diabetes mellitus)? If it's secondary diabetes but not due to an underlying condition or drug and is not chemically induced, what kind of diabetes could it be?
CMS made incorrect payments to hospitals for established patient clinic visits estimated at approximately $4.6 million in 2012, according to a recent Office of Inspector General (OIG) audit.
The switch to ICD-10-CM won't bring many changes in the codes for reporting genital prolapse, but understanding the nuances of the diagnoses is key for choosing the correct code. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, highlights terms to look for in documentation and provides a sample operative report to test your knowledge.
Every have one of those days when you feel like you’ll never be warm? I’m having one of those. One of the downsides to have a window cube is the cold seeps in with the sunshine. Or with the dreary...
Auditors continue to scrutinize inpatient wound care services. Glenn Krauss,BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, reviews the importance of documenting medical necessity for these services.
