When an error occurs in coding, sometimes the coders miscodes a record, but in others, the documentation is deficient, leading to incorrect code assignment. Joy Strong, PMP, Donielle Bailey, RHIA, and Jill M. Young, CPC, CEDC, CIMC, discuss how good documentation and accurate coding go hand in hand.
The majority of respondents in our recent (unscientific) JustCoding poll identified physician documentation as their biggest concern heading into the ICD-10 transition. No one should be surprised by...
Coding for podiatry services requires an extensive understanding of complex anatomy and regulations. Lynn M. Anderanin, CPC, CPC-I, COSC , AAPC Certified ICD-10-CM instructor, AHIMA Approved ICD-10-CM trainer, reviews what steps coders can make to ensure complete documentation for podiatry services that are facing increasing audits.
The 2014 IPPS Final Rule was supposed to be implemented with enforcement beginning October 1, but one of its most controversial aspects has seen another delay in enforcement, with major healthcare trade groups seeking more.
Q: We recently had a situation where a patient had come in to have his port re-assessed. He had been complaining of the port being difficult to access. Preliminary x-ray showed the port accessed, with great blood return. Patient has an allergy to IV contrast, so we just flushed the port, and did not give the contrast. The port remained accessed. How do we code this? Do we use 36598 (contrast injection[s] for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report) with a modifier -52 (reduced services)? The other option is a modifier -73 (discontinued outpatient procedure prior to anesthesia administration) or -74 (discontinued outpatient procedure after anesthesia administration). However we have no documentation regarding anesthesia, and I'm not sure the patient would even get anesthesia for a procedure such as this.
ICD-10-CM codes may look completely different, but many of the coding steps remain the same. Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD; Julia Palmer, MBA, RHIA, CCS ; and Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, FAHIMA, CDIP, AHIMA-approved ICD-10-CM/PCS trainer explain how to code for neoplasms in ICD-10 and which changes to note.
Mr. Jack O. Lantern underwent some significant surgery at Stitch ‘Em Hospital back on October 16. Dr. Carver removed Jack’s liver, stomach, large intestine, small intestine, appendix, and gall...
Which tasks have you completed on your ICD-10 implementation list? We want to know. Our sister publication , Medical Records Briefing, is conducting a benchmarking survey on ICD-10 implementation,...
Initially, we thought that outpatient coders didn’t have to learn to code in ICD-10-PCS. They would still use CPT® codes to report physician services in the outpatient world. Now it looks like that...
Recovery Auditors are data mining for sepsis MS-DRGs and then focusing in on those with a short length of stay. Robert S. Gold, MD, and Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, provide tips for correct sepsis coding to avoid auditor takebacks.
A wound is an injury to living tissue caused by a cut, blow, or other external or internal factor. Robert S. Gold, MD , and Gloria Miller, CPC, CPMA , review anatomy and documentation for wounds and explain how to code for wound care in ICD-9 and ICD-10.
The ICD-10 implementation will result in a slowdown at every level of coding. Elaine O’Bleness, MBA, RHIA, CHP, Migdalia Hernandez, RHIT, Kimberly Carr, RHIT, CCS, CDIP, and Rachel Chebeleu, MBA, RHIA, provide suggestions on how to minimize that productivity decline.
Physicians believe they are providing quality care, which gives them high job satisfaction. However, the problems associated with using electronic health records decreased that satisfaction, according to a recent RAND survey.
In this month's issue, we explain how coders will report sepsis in ICD-10-CM, go beyond pressure ulcers for coding wound care, review the importance of PEPPER, and reveal how to uncover and correct documentation deficiencies before ICD-10 implementation. Dr. Robert Gold introduces you to SIRS and our coding experts answer your questions.
In this month's issue, we review ICD-10-CM guidelines, illustrate how neoplasm coding will and won't change in ICD-10-CM, identify elements for appropriate ED E/M level selection, and answer your coding questions.
How well could you code in ICD-10 using your current physician documentation? Do your physicians document the specificity and detail coders need to select the correct ICD-10-PCS code? Do your physicians document laterality, which coders will need for many ICD-10-CM codes?
Our experts answer questions about followup visits in the ED, skin substitutes, flu vaccines, osteoporosis and fractures in ICD-10-CM, ICD-10-CM external cause code, modifier for discontinued cardioversion, and modifier -25
All pressure ulcers are wounds, but not all wounds are pressure ulcers. A wound is an injury to living tissue caused by a cut, blow, or other external or internal factor. Wounds usually break or cut the skin.
Coders select E/M levels based on criteria developed by their organization. CMS has proposed a significant change to E/M coding-replacing the current 20 E/M levels for new patients, existing patients, and ED visits with three G codes-but that change would only apply to Medicare patients and only to the facility side.
