Coding tells a patient's story, based on the narrative the physician provides in his or her documentation. 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 payment.
Coding professionals may inappropriately assign codes from parts of the medical record where the doctors, early in the workup of a complex patient, were describing differential diagnoses in their evaluation of the patient. Robert S. Gold, MD, discusses whether coders should report every diagnosis mentioned in a patient’s chart.
Since portions of the reproductive system use some of the same structures as the urinary system, including the urethra, codes for conditions involving both male and female reproductive systems appear in Chapter 14 of ICD-10-CM, Diseases of the Genitourinary System.
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.
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.
As new and more effective treatment options are created and evaluated, AMA must update the CPT® Manual to add and revise codes that allow providers to accurately report the work they performed. The 2015 updates include more than 500 changes, including more than 250 new codes that impact nearly every section. In the 2015 CPT Manual, only the integumentary and respiratory system sections remain unchanged.
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...
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?
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 .
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.
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.
