Q: We have gotten conflicting advice regarding ICD-10-CM code categories B95-B97 (Bacterial and viral infectious agents) regarding CCs, MCCs, and severity of illness/risk of mortality. Could you clarify the impact of reporting causative organisms?
Systemic inflammatory response syndrome (SIRS) criteria has a greater sensitivity than quick sepsis-related organ failure assessment (qSOFA) as a screening test to initiate treatment for sepsis in non-intensive care unit patients, according to the recent study published in the Annals of Internal Medicine.
Danielle Richmond says that while inpatient coder shortages are nowhere near what they were with ICD-9-CM, new challenges have emerged. This article shares important advice for any managers trying to improve their coder recruitment and hiring process.
James S. Kennedy, MD, CCS, CCDS, CDIP, writes that clinical validity, documentation, and ICD-10-CM coding applicable to liver disease remains a great challenge to those invested in severity and risk-adjustment coding compliance. In this article, he reviews several pitfalls that could await facilities.
Coders often seek definitions for realistic productivity benchmarks, and standards depend on how a given facility establishes the responsibilities and expectations of its team. Therefore, before assessing a coder’s success, a facility must set goals that define that success. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
It’s estimated that more than half a million people in the U.S. are diagnosed with Crohn’s disease. Debbie Jones, CPC, CCA , outlines symptoms and treatments for Crohn’s disease, as well as ICD-10-CM coding for the condition and associated complications.
CMS held a listening session March 21 to gather input from stakeholders on potential updates to the E/M documentation guidelines. The current guidelines are considered outdated in light of medical advances and the advent of the electronic health record.
Almost 70% of Americans are considered overweight or obese. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS , reviews ICD-10-CM coding and HCC risk adjustment for obesity.
Coding for hydration and chemotherapy administration can be a daunting task for both beginner and experienced coders, who may not understand the hierarchy rules and gray areas in the CPT guidelines. Review correct coding for these services and how they fit into the hierarchy. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Yvette M. DeVay, MHA, CPC, CPMA, CIC, CPC-I , reviews the anatomy of the brain and details treatments and surgeries associated with the brain and how to report them in ICD-10-CM/PCS.
Laura Legg RHIT, CCS, CDIP, looks at the results of Central Learning’s second annual ICD-10 Coding Contest and highlights ways facilities can use the data to improve coding performance and accuracy. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: We are having trouble determining what qualifies a patient as having an acute myocardial infarction (MI) and what documentation would support the diagnosis. Can you help our coding team clarify?
Of emergency department visits attributable to ruptured abdominal aortic aneurysm, acute myocardial infarction, stroke, aortic dissection, and subarachnoid hemorrhage, the conditions were not accurately diagnosed approximately one out of 20 times, according to a study by the Journal of the American Medical Association (JAMA) .
Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, writes that even though CDI specialists are not coders, it’s important to learn the rules and guidelines that coders follow. CDI teams need to reference guidance and guidelines in their daily work to ensure documentation is clear, concise, and supportive of accurate code assignment true to the patient’s story.
To help bring JustCoding members together and let them learn more about their colleagues, JustCoding created a monthly member spotlight to appear in upcoming issues. This month, we are pleased to intoduce Tracy C. Harris, RHIT, CCS, coding manager at New England Baptist Hospital in Boston.
The shift from fee-for-service to value-based programs for outpatient payment systems has increased the need for outpatient CDI staff to review documentation for pertinent clinical factors.
Providers should be preparing for another rulemaking cycle from CMS as we hit April, with the IPPS rule expected to include a discussion on how the existing payment system can address new and emerging cellular and gene therapies.
With the expansion of telehealth services, providers for both the originating site and distant site can also count on the expansion of Medicare contractor audits.
