Q: A patient with undiagnosed syncope is admitted to observation. Later that evening, the patient is diagnosed with syncope and develops complications that warrant an inpatient admission. Should the patient be considered an inpatient from the time inpatient criteria are met or from the time the inpatient order is written?
Coders remain highly accurate when reporting present-on-admission (POA) indicators, but they need to maintain that accuracy. The OIG reiterates the importance of POA reporting in terms of monitoring hospital quality of care and the role that such reporting plays in CMS’ effort to align payment incentives with patient outcomes. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, and Nena Scott, MS, RHIA, CCS, CCS-P, offer tips to ensure complaint POA reporting.
Based on the prevalence of commercials for acid reflux remedies, you’d think the entire country suffered from some sort of digestive disease. Maybe some of it comes from coders who are sick to their...
There’s a bigger picture to the preparation for ICD-10 than just coding productivity. The bigger picture includes doing the process improvement now that is needed to break down all barriers to...
Q: In ICD-9-CM we only have one type of Excludes note. ICD-10-CM uses Excludes1 and Excludes2. What is the difference between the two types of Excludes notes and how do they relate to Excludes notes in ICD-9-CM?
If you think you’ve estimated the right amount of training time for ICD-10-CM, you probably should increase it. Cindy Grant, CHIM , Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, and Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, explain why organizations will need to plan additional hours of training for ICD-10-CM.
The International Classification of Diseases (ICD) was originally referred to as the Uniform Classification of Causes of Death. Robert S. Gold, MD , reveals why ICD in the United States doesn't correlate well with the systems in other countries and omits various important clinical conditions that can cause fatal outcomes for patients.
CMS is currently updating its ICD-10 implementation guides for practices, small hospitals, and payers. The agency has already posted the updated guide for small and medium practices .
Anatomy hasn’t changed in hundreds of years, but with the additional specificity required in ICD-10-CM, coders will need to brush up on their knowledge . Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-Approved ICD-10-CM/PCS Trainer, takes coders on a tour of the respiratory system and compares ICD-9 and ICD-10-CM coding for some respiratory conditions.
Many musculoskeletal conditions are a result of previous injury or trauma to a site, or are recurrent conditions. If a patient presents with a bone, joint or muscle conditions that are the result of...
Our coding experts answer your questions about physician supervision for chemotherapy, billing injectable drugs, Addendum B and coverage, new transitional care management codes, and stent placement with other procedures.
Everyone knows that CCs and MCCs are under scrutiny these days. However, that doesn't mean hospitals should err on the side of caution when reporting these conditions. William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla., provides several tips that coders can employ to look for clinical evidence in the record before querying for these targeted conditions.
In this month's issue, we examine interventional radiology coding for nonvascular procedures, review new CPT nuclear medicine codes, highlight important changes to the I/OCE, and answer your questions.
The AMA added five new nuclear medicine codes to the radiology section of the 2013 CPT Manual , while revising and deleting a number of codes that represented outdated technology or were bundled into placement procedures.
When coders hear the words "interventional radiology," many think of vascular procedures. However, interventional radiology encompasses additional, nonvascular procedures, such as nephrostomy tube placement and drainage of abscesses.
The advent of electronic media is slowly but surely changing the way we access information. Hospitals and physicians are transitioning from paper and hybrid medical records to EHRs. Estimates indicate that nearly half of all Internet users send or receive email daily, according to EzineArticles.com .
Everyone knows that CCs and MCCs are under scrutiny these days. However, that doesn't mean hospitals should err on the side of caution when reporting these conditions. William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla., provides several tips that coders can employ to look for clinical evidence in the record before querying for these targeted conditions.
