Coders may struggle to differentiate the ICD-10-PCS root operations excision and resection. Nena Scott, MSEd, RHIA, CCS, CCS-P, AHIMA-approved ICD-10-CM/PCS trainer, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, explain why excision is the root operation of choice for excisional debridement and sebaceous cyst removal.
James S. Kennedy, MD, CCS, discusses the increased clinical specificity required for coders to report strokes and transient ischemic attacks in ICD-10.
Coders and clinicians seem to speak different languages. CDI specialists often serve as the translators between clinicians and coders, so it's important that all three groups work together. Cheryl Ericson, RN, MS, CCDS, CDIP , AHIMA-approved ICD-10-CM/PCS trainer, Darice M. Grzybowski, MA, RHIA, FAHIMA , Jonathan Elion, MD, Kathy DeVault, RHIA, CCS, CCS-P , and William E. Haik, MD, FCCP, CDIP , offer tips for determining when to query.
Almost all of the ICD-10-PCS root operations describe very specific intent. Think about the difference between root operations excision and resection. Excision involves removing some of a body part...
The auditory system has its own code category in ICD-10-CM because of the number of new codes and specificity available. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I , reviews ear anatomy and how to report newly introduced diseases and conditions.
Not surprisingly, coders will have many more options to report how a patient was injured in ICD-10-CM. Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD , and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS , explain how the codes differ from ICD-9-CM E codes, when to report them, and why coders should not be too worried about the transition.
CMS Administrator Marilyn Tavenner reiterated last week that ICD-10 implementation would not be delayed again, as CMS prepares for end-to-end testing of providers this summer.
Coders will have many more options to report wrist and hand injuries in ICD-10-CM, with codes for individual fingers, wrist bones, and joints, as well as laterality. Review the anatomy of the wrists and hands in order to take advantage of the specificity available in ICD-10-CM.
Q: I am auditing a note for a fusion. The note lacks detail, therefore is hard to justify. The patient had a prior hardware placement. The note describes dissecting down, debridement of necrotic bone, and tissue work done. This is the entire note, after describing dissection, “Vigorous irrigation with 10 liters of saline and antibiotics was carried out. Hemostasis was maintained. The right S1 screw and rod portion was removed as it was notably loose. Additional decortication and onlay bone grafting was performed at L1-S1. Drains were placed…” They coded: 22612 (arthrodesis, posterior or posterolateral technique, single level; lumbar) Add-on code 22614 (each additional vertebral segment) x4 22852 (removal of posterior segmental instrumentation) In the procedures performed area of the note, they state: Hardware removal, lumbar Revision fusion L1-S1 with onlay bone graft Irrigation and debridement of lumbar spine wound Since there is nothing in the note regarding autografting, I assume this is an allograft? Should this be coded? Also is that documentation enough to justify arthrodesis? Modifier -GC (this service has been performed in part by a resident under the direction of a teaching physician) was appended, although the language was not added for this. I can only assume a resident dictated this.
Inpatient coders are used to being able to code conditions documented as possible, probable, suspected, or rule out, as if they were in fact confirmed. Outpatient coders can’t do that. They need a...
Coders and clinicians seem to speak different languages. CDI specialists often serve as the translators between clinicians and coders, so it's important that all three groups work together.
In this month’s issue, we explain how to differentiate between ICD-10-PCS root operations excision and resection, review when and how to query physicians, and provide a basic introduction to APR-DRGs. You’ll also find a Q&A with Sherine Koshy, MHA, RHIA, CCS, corporate director of HIM coding for University of Pennsylvania Health System in Philadelphia. Robert S. Gold, MD, highlights some additional areas of concern in ICD-10-CM in this month’s Clinically Speaking column.
CMS has been making it clear over the years that packaging would become a larger and larger part of OPPS, and in calendar year (CY) 2014 CMS made good on this.
In this month's issue, we review latest 2014 CPT ® Manual changes, examine how MUEs are determined, take a look at wrist and hand anatomy in preparation for the increased specificity of ICD-10, and answer your coding questions.
ICD-10-CM root operations excision and resection are sometimes hard to differentiate. ICD-10-PCS defines excision (B) as cutting out or off, without replacement, a portion of a body part. Resection (T) is almost identical, but involves cutting out or off the entire body part.
