Q: If the physician documents “concerning for,” “considering,” “cannot be ruled out,” or “cannot be excluded” for a diagnosis, is that considered an uncertain diagnosis? Can those terms be coded if the patient is being worked up? Are the terms “concerning for” and “considering” equal to the uncertain diagnosis terms “yet to be ruled out”?
Drainage procedures can be therapeutic in nature or diagnostic, such as when a physician removes a fluid or gas for biopsy. A nita Rapier, RHIT, CCS, Nelly Leon-Chisen, RHIA, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS , highlight the differences in coding diagnostic and therapeutic thoracocentesis and lumbar tap procedures in ICD-10-PCS.
With Recovery Auditor audits on hold, hospitals may have experienced a decrease in the number of audits that must be addressed. Cathie Wilde, RHIA, CCS, and Kim Carr, RHIT, CCS, CDIP, CCDS, explain why organizations still need to be able to justify code assignment.
The absolute best ICD-10 education is completely free, assuming you have an Internet connection. It will tell you everything you need to know about coding in ICD-10. What is this magical, mystical...
Armadillos apparently pose more hazards to your health than just passing on leprosy. A Texas man recently tried to shoot an armadillo three times and ended up being hit by his own bullet . He claims...
Hospitals did not get any ICD-10 relief as part of CMS’ accord with the AMA regarding a specificity grace period . However, they might not need much help, according to the latest Workgroup for...
CMS has released a document to clarify questions providers raised about its recent guidance on ICD-10-CM, including answers on how the agency is defining a family of codes.
Q: We had a patient come into our ED with a severe head injury. To protect his airway, we intubated the patient. Can we report an emergency endotracheal intubation (CPT ® code 31500) and CPR (92950) together if only bagging happens and no chest compressions?
Organizations have their hands full with ICD-10-CM implementation finally on the horizon. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, and AHIMA-approved ICD-10-CM/PCS trainer, examines how coding departments can clean up their processes now so they are ready for the new code set.
CMS has repeatedly tweaked its logic regarding comprehensive APCs since inception. Dave Fee, MBA, reviews the latest changes regarding complexity adjustments, as well as new and deleted codes.
Coders may need to review the anatomy of the gastrointestinal system and disease processes for gallstones, hemorrhoids, and ulcerative colitis to choose the most specific ICD-10-CM code. Jaci Johnson Kipreos, CPC, CPMA, CEMC, COC, CPC-I, and Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, explain aspects of anatomy and what coders will need to look for in the documentation.
Bacteria are everywhere. Literally. And you can’t see them or feel them. In fact, trillions of them are living on your skin right now. So not all bacteria are bad. Some, though, can do nasty things...
Physician groups have led much of the resistance against ICD-10 implementation. At its June Delegates meeting, the AMA approved a resolution from W. Jeff Terry, MD, for a two-year grace period to protect physicians from errors and mistakes related to the code set. Terry also authored an AMA resolution to delay ICD-10 in November 2011, which led to postponing implementation until October 1, 2014.
Ask a physician why he or she documents in the medical record and you'll get a variety of answers. Some physicians will say they document because the medical records people hound them for the information, or they do it so they get paid. They may also say they do it to complete the medical record.
In this month's issue, we speak with physicians about queries in ICD-10-PCS and look at some specialty-specific procedures that may require queries. We offer tips on how to differentiate between ICD-10-PCS root operations Excision and Resection and review the changes CMS proposed to the 2-midnight rule. Robert S. Gold, MD, reveals how to use audit findings to your advantage.
It's great, identifying opportunities to teach. Whenever I do medical record audits, I always look for chances to educate coders, physicians, and/or CDI specialists about areas of misunderstanding by coding professionals or elements of patient experience that require specific documentation for proper code assignment.
ICD-10-PCS root operations Excision and Resection differ only in how much of a body part is removed. Review these situations to clarify which root operation to report.
We're less than four months away from the implementation of ICD-10-CM/PCS, and the AHA Coding Clinic for ICD-10-CM/PCS is rolling right along with advice for the new code set.
