As healthcare professionals, we’re all familiar to some degree with HIPAA. You know, the law that makes it illegal to release protected health information, among other things. Hospital employees have...
One of the biggest stumbling blocks for ICD-10 implementation by small physician practices was the estimated cost of the transition. Those costs may not be as high as originally estimated, according...
Ever play with a Magic 8 Ball? (If not, there’s an app for that.) Ask it a question, shake it up, and get an answer. Usually something vague (and vaguely ominous) like, “Reply hazy try again.” Asking...
Nearly 30% of Medicare patients are enrolled in Medicare Advantage (MA) programs, which come with specific coding and documentation challenges. Elaine King, MHS, RHIA, CHP, CHDA, CDIP, FAHIMA, and Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, highlight key requirements for reporting diagnoses that map to Hierarchical Condition Category codes, the basis of MA plans.
Q: I work in a large, provider-based orthopedic clinic with a rheumatology department that has many patients who are very ill with several comorbid conditions. Does the physician need to document every comorbid condition that impacts his or her medical decision making for each encounter? Do we need to code every comorbidity each time in order to meet hierarchical condition category (HCC) requirements?
The House of Representatives recently passed a bill that would impact supervision levels for certain outpatient services. Debbie Mackaman, RHIA, CPCO , reviews the impact of the legislation and which provider types and services it would affect.
CMS finalized a new data collection requirement for services performed in off-campus, provider-based clinics in the 2015 OPPS final rule , which was released October 31.
You may have noticed that the ICD-10 manuals have the word “draft” splashed all over them. (If you have an actual paper ICD-10 manual that is. The PDFs don’t include the word draft.) I had someone...
Welcome to OR 13 at the Stitch ‘Em Up Hospital, where Dr. Hack N. Slash is preparing for today’s procedure. And what is today’s procedure? Dr. Slash is performing a cut down and suturing of a...
ICD-10-CM is similar to ICD-9-CM, but coders need to watch out for differences which could lead to incorrect coding. Nelly Leon-Chisen, RHIA, Gretchen Young-Charles, RHIA, and Sarah A. Serling, CPC, CPC-H, CPC-I, CEMC, CCS-P, CCS , discuss possible pitfalls for coding myocardial infarctions, neoplasms, and external causes in ICD-10-CM.
Coders need to understand the different approaches for procedures in ICD-10-PCS because they're required and the new system does not include default or unspecified options. Laura Legg, RHIT, CCS, Nena Scott, MS, RHIA, CCS, CCS-P, and Gretchen Young-Charles, RHIA, explain the different approaches and address gray areas for selecting the most appropriate character.
Q: The primary physician documented subacute cerebral infarction and I am wondering whether I should code this to a new cerebral vascular accident (CVA) or not, since the term “subacute” doesn’t really fall anywhere.
Many physicians remain reluctant to admit when a complication occurs as the direct result of the medical care they provide. Trey La Charité, MD , reviews hypothetical situations to help illustrate how coders and clinical documentation improvement specialists can handle complications.
Beginning January 1, 2015, physicians will no longer need to provide certification for an inpatient admission unless the admission is expected to last for 20 days or longer or the case is an outlier.
Gerri Walk, senior manager of technical training for HRS in Baltimore, had the absolute best reason for learning to code in ICD-10. During the 2013 AHIMA National Conference in Atlanta, Gerri...
Editor's note: Jugna Shah, MPH, president and founder of Nimitt Consulting, writes a bimonthly column for Briefings on APCs, commenting on the latest policies and regulations and analyzing their impact on providers.
Many coders rely on the advice in the American Hospital Association (AHA)'s Coding Clinic to resolve sticky situations with ICD-9-CM coding. However, the AHA will not be transitioning its current guidance to ICD-10-CM. Instead, in January, it began focusing solely on ICD-10-CM questions to help clear up confusion prior to implementation.
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician documentation to accommodate the new code set was a top concern for the healthcare industry.
ICD-10-PCS codes consist of seven characters, each of which identifies a unique, specific piece of information. For most of the codes in the Medical and Surgical section, each character represents the same information every time.
In this month's issue, we explain the clinical and coding aspects of malnutrition, review the possible approaches in ICD-10-PCS, and discuss Coding Clinic clarifications for ICD-10. Robert S. Gold reveals when to report a transbronchoscopic lung biopsy.
