Interventional radiology cases are often complex with confusing coding rules, especially for radiologic supervision and interpretation. Stacie L. Buck, RHIA, CCS-P, RCC, CIC, and Karna W. Morrow, CPC, RCC, CCS-P, lead you through the maze of coding these procedures.
Q: A patient went to the operating room under anesthesia for cataract extraction and repair of retinal detachment of the same eye. The surgeon successfully removed the cataract. The surgeon then accessed the back of the eye to begin to repair the detachment. After reviewing the condition of this eye area, the surgeon determined that the eye was in such bad shape it could not be saved, so the detachment was not repaired and surgery was ended. The patient was under anesthesia and the retinal detachment repair procedure was begun (although barely) but then cancelled. Should we report this procedure since the facility incurred expenses for the surgical attempt at repair?
It’s Groundhog Day…over and over in the comedy Groundhog Day. Poor Phil Connors (played by Bill Murray) does his best to escape the never-ending cycle by killing himself in some creative ways. It’s...
We’re all thinking about documentation specificity needs in ICD-10-CM/PCS as we prepare of the October 1, 2014 compliance deadline. Increased communication between physicians and coders is paramount...
As Lucile Packard Children's Hospital in Palo Alto, Calif., implemented its EHR, the dreaded problem of copy and paste documentation began to rear its ugly head.
Physicians and other providers practice in many different areas within a hospital. To accurately code physician and provider services, coders must know and understand the place of service (POS) codes.
The ICD-9-CM guidelines state that it's unusual for two or more diagnoses to meet the definition of principal diagnosis. However, coders know this isn't exactly true, as the scenario tends to occur frequently.
In November 2011, the FDA approved transcatheter aortic valve replacement (TAVR) to treat aortic valve stenosis for those patients who are not candidates for traditional open-heart surgery. This procedure is also referred to as a transcatheter aortic valve implantation (TAVI).
As Lucile Packard Children's Hospital in Palo Alto, Calif., implemented its EHR, the dreaded problem of copy and paste documentation began to rear its ugly head.
One of the major changes to the 2013 CPT Manual is the replacement of the term "physician" with "physician or other qualified healthcare professional" (QHP) in a wide range of codes.
In times of increased auditor scrutiny, it's important for coders to remind themselves of their strengths. Assigning the POA indicator is one of them, according to an OIG report released in November 2012.
In this month's issue, we review the overhaul of CPT's psychiatry section and new codes for cardiology procedures, examine CPT's new provider neutrality language, and examine place of service codes.
Underdosing is a new coding concept in ICD-10-CM and it has its own column in the table of drugs. Underdosing can be accidental (patient forgot to take the medication) or intentional (patient chose...
Q: One of our orthopedic surgeons started to perform spinal fusions percutaneously. CPT ® provides instruction on how to code this procedure; however, these are inpatient surgeries, so we need an ICD-9-CM code. We’re leaning toward code 81.00 (spinal fusion unspecified). Do you think this is the correct code?
Electronic health records (EHR) provide opportunities for more efficient and effective care, yet they also provide coding and documentation challenges. Jill M. Young, CPC, CEDC, CIMC, explains what coders need to be wary of when coding from an EHR.
If you’re curious about whether something you’ve heard or read about the Recovery Auditor program is true, be sure to check out new information published on the CMS Web site. The agency released a document that addresses 14 common myths about the program.
