Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS , and Susan E. Garrison, CHCA, CHCAS, PCS, FCS, CPC, CPC-H, CCS-P, CHC, CPAR, examine a pair of case studies to determine whether the right codes were applied and whether it's appropriate to append a modifier.
Q: I work for general surgeons. Here is a common scenario: The surgeon is called in to see patient in the ED for trauma or consult. The patient is admitted, but our physician is not the admitting physician. I would tend to bill the ED code set, but do I have to use the subsequent hospital care codes instead?
Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I , examines common orthotic procedures, including fracture reduction, total knee replacement, and total hip replacement, to determine how to choose the correct CPT ® code and key terms that should be documented.
Poor Finn is having a rough week. It started out well as he spent Sunday with his folks and older brother at an amusement park being as amused as a 6-month-old can be. Things started going downhill...
Jeff comes in to the Fix ‘Em Up Clinic complaining of shortness of breath, a persistent cough, tightness in his chest, and frequent respiratory infections. He tells Nurse Nosey that he smokes a pack...
CMS focused on quality measures in the 2015 IPPS proposed rule, released April 30. Kimberly A.H. Baker, JD, Cheryl Ericson, MS, RN, CCDS, CDIP, James S. Kennedy, MD, CCS, CDIP ,and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, highlight the most significant proposed changes.
Sequela, or late effect, is the remaining or lasting condition produced after the acute stage of a condition or injury has ended. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, reviews the correct way to code for sequelae in ICD-9-CM and ICD-10-CM.
Learning to code in ICD-10-PCS is in some respects like learning a language, you need a strong foundation in the rules. Sue Bowman, MJ, RHIA, CCS, FAHIMA , Gerri Walk, CCS-P , Nena Scott, MSEd, RHIA, CCS, CCS-P , and Jennifer Avery, CCS, CPC-H, CPC, CPC-I, discuss the guidelines related to root operations in ICD-10-PCS.
For anyone who has not yet started ICD-10 training, CMS posted a transcript, audio file, and slide presentation from the June 4 More ICD-10 Basics MLN Provider call on its website.
Q: A few days into the patient’s stay, an order for a Foley catheter was placed for incontinence and around the same time the physician documented a urinary tract infection (UTI). Would it be appropriate to query the physician regarding the relationship of the UTI to the Foley? Our infection control department caught this but we did not. I am concerned about this for two reasons; first, I worry about writing a leading query and second, whether the UTI could be considered a hospital-acquired condition (HAC) if additional documentation isn’t provided.
Dodge ball is not a game for wimps or the uncoordinated. Even master ball dodgers can end up in the Fix ‘Em Up Clinic. Steve engaged in a spirited game of dodge ball over the weekend, which resulted...
What do you get when you combine a full moon and Friday the 13th? Some really odd injuries at the Fix ‘Em Up Clinic. Fortunately, we here at the clinic suffer from neither paraskevidekatriaphobia (...
I recently spoke with Barbara Hinkle-Azzara, RHIA , vice president of HIM operations for HRS Coding in Baltimore about preparing for ICD-10 and, more specifically, about the anticipated MS-DRG...
Guidance for coding OB delivery lacerations sometimes differs between the CPT ® Manual and the American Congress of Obstetricians and Gynecologists. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , explains the difference in guidance and documentation necessary to report tears to the proper degree.
Q: If the clinical impression is physical assault, vomiting, blunt injury to abdomen, and head injury with loss of consciousness, can I code the history of hypertension, diabetes mellitus, headache, bipolar disorder, and depression?
On July 1, CMS will implement a variety of changes to current supervision requirements as recommended by the Hospital Outpatient Payment Panel. Debbie Mackaman, RHIA, CHCO , reviews the panel's recommendations, and which CMS plans to accept or reject.
A patient comes into the ED following an automobile accident. The physician documents that the patient has an open, displaced fracture of the lateral condyle of the right tibia. The physician also...
We all know that ICD-10 codes will require more complete documentation. We’ve been telling physicians that, but maybe we’re not explaining it well or correctly. What makes documentation better? It’s...
