Q: Can CDI programs use the information on ambulance forms or trip tickets to abstract from if the information is pulled into or reiterated in the ED or history and physical (H&P) documentation? Our staff doesn’t want to miss criteria that would diminish our ability to substantiate the true severity of illness of some patients, but I have been informed that coders are not allowed to code from ambulance papers or information.
Coders and clinical documentation improvement specialists often focus on different information when reviewing documentation for heart disease. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Cheryl Ericson, MS, RN, CCDS, CDIP, highlight the different perspectives.
Coders and clinical documentation specialists can use queries to improve physician documentation of a patient’s severity of illness and risk of mortality. Rhonda Peppers, RN, BS, CCDS, and Sara Baine, MSN-Ed, CCDS, walk through a case study to highlight query opportunities.
Tobie comes into the Acme ED Tuesday complaining of stomach cramps, nausea (but no vomiting), light-headedness, and chest pain. What in the world could be wrong with Tobie? Dr. H.M. Lock examines...
Quick, what’s the ICD-9-CM code for diabetes? I bet you knew it was 250.00. What’s the ICD-10-CM equivalent? Does ICD-10-CM even have an equivalent, since 250.00 is very vague? Yes, we do have a...
CMS' January I/OCE update brought many changes, including new codes, status indicators, and modifiers. Dave Fee, MBA, reviewsthe latest changes and when they will be implemented by CMS.
Debbie Mackaman, RHIA, CPCO, CCDS, discusses modifier -59 (distinct procedural service) use, including the latest guidance from CMS on the four new, more specific replacements—and how more guidance is needed before providers can feel comfortable using them.
Providers report excessive units for initial IV infusions for both chemotherapy and non-chemotherapy drugs, according to the results of an audit reported in the January 2015 Medicare Quarterly Provider Compliance Newsletter .
Q: Would it be appropriate to report CPT ® code 75984 (change of percutaneous tube or drainage catheter with contrast monitoring [e.g., genitourinary system, abscess], radiological supervision and interpretation) for the following procedure: A small amount of contrast was injected through the indwelling nephrostomy drainage catheter. This demonstrated the catheter is well positioned within the renal collecting system. There is a small amount of thrombus attached to the tip of the pigtail catheter. The existing catheter was cut and a guidewire was advanced through the catheter into the renal collecting system. The existing catheter was removed over the wire and exchanged for a new 10 French nephrostomy tube. The catheter was secured to the skin with 2-O suture and covered with a sterile dressing.
CPT ® codes in 2015 for cardiovascular procedures include the ability to report several new technologies and procedures. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, explain the procedures and what coders will need to look for in documentation to select the correct code.
Ah, Fat Tuesday (AKA Mardi Gras), the last big blowout before Lent begins. For those not of a religious bent, it’s still a good reason for an all-day party. Here at the Fix ‘Em Up Clinic, we have...
My true love did his best over the weekend to make up for the 12 days’ worth of bad gift giving at Christmas. Alas, the best(?) laid plans of mice and men often go astray. My true love’s first...
Implementation costs and plans took center stage at The House Energy and Commerce Committee’s subcommittee on health’s ICD-10 Implementation hearing today. Seven witnesses testified before the...
Q: A patient comes in with a malunion of a fracture. A different physician treated the patient initially for the fracture, but the patient came to see our physician for surgery to repair the malunion. Which seventh character should we use: A for initial encounter or P for subsequent encounter for fracture with malunion?
CMS is adequately preparing to implement ICD-10 October 1, according to a new Government Accountability Office (GAO) report detailing CMS’ transition efforts.
Coronary artery bypass graft procedures are not the only ones coders will report using the root operation Bypass in ICD-10-PCS. Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, and Lisa Crow, MBA, RHIA, explain how to code for other bypass procedures in ICD-10-PCS.
The ICD-10-PCS Manual includes 17 different sections, including Administration. Learn how to assign codes from this section to prepare for ICD-10-PCS implementation.
