And the new proposed ICD-10-CM/PCS implementation date is (drum roll, please)…October 1, 2014. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced the new date as part...
When a physician moves a body part to a new place without disrupting its vascular and nervous supply, coders will code to root operation Transfer in ICD-10-PCS. The root operation is indicated by the...
My feet are killing me. I wonder what the problem is. Let’s see what it could be and how we would code it in ICD-10-CM. I got a new pair of shoes, so maybe the problem is a blister. That should be...
Several years ago, a pharmaceutical company came under fire because its sales reps were pushing the company’s drugs using Tigger and Eeyore, two popular characters from the "Winnie the Pooh" series...
Our coding experts answer your questions about molecular pathology codes, HCPCS codes for drugs that aren’t separately payable under OPPS, deducting push time from infusions, CPT initial observation codes, and diabetes coding in ICD-10-CM.
Editor’s note: To help coders prepare for the upcoming transition to ICD-10-CM, we will provide occasional articles about specific anatomical locations and body parts as part of a larger series for ICD-10-CM preparation. This month’s column addresses digestive system.
The transition to ICD-10-CM is coming. The only question is when. Despite the delay, coders and other HIM professionals must continue to prepare for the transition.
Coders and billers may not completely understand how to charge for inpatient supplies. One misconception is that the room rate incorporates all supplies used for every inpatient. Another misconception is that payers will not separately pay for inpatient supplies.
This month's issue feautres articles on separately charging for inpatient supplies, an introduction to ICD-10-CM, anatomy of the digestive system, and our coding Q&A.
Learn about coding and medical necessity, planning internal coding audits, potential Medicaid RAC target areas, physician queries, and physician documentation and ICD-10-PCS.
Coding isn't just about reading documentation and selecting codes based on certain words. It's about processing information and assessing whether the codes reported accurately depict the clinical picture and medical necessity for an admission.
The Medicaid RAC program kicked off January 1, and experts say that although the program got off to a slow start, activity will likely ramp up in the next few months.
Spring is in the air and Anytown just held its combined Spring Festival and Easter egg hunt. I’m sad to say things did not go smoothly, judging by the number of patients in the Fix ‘Em Up outpatient...
When a physician completely closes the orifice or lumen of a tubular body part, coders will look to the root operation occlusion in ICD-10-PCS. The orifice can be a natural orifice or an artificially...
These days, documentation improvement and compliance are at the forefront of coders' minds. In some cases, coders are led completely astray by bad data and physician documentation that isn't entirely accurate. Robert S. Gold, MD, emphasizes that it’s important for coders to always look at the larger clinical picture in the medical record—not just a documented laboratory result or change in vital sign. Gold applies this philosophy and examines a number of conditions, including anemia, acute kidney injury, congestive heart failure, and myocardial infarction.
QUESTION: We are having a discussion about how to code when the studies section of the history and physical (H&P) indicates that the chest x-ray showed atelectasis or that an electrocardiogram showed right bundle branch block with anterior fascicular block. Some of us believe that it’s okay to code the diagnosis (i.e., atelectasis) if the provider states that the testing “showed” the diagnosis, whereas others believe we cannot code the diagnosis as it is a lab/testing result, and the provider could just be reading the results onto his or her H&P dictation. I realize you cannot go to the testing result itself and code from it directly. However, I argue that it would be okay to code for it because the provider is using this information to make decisions about care, testing, and procedures, and he or she indicates the testing results in the H&P body. What are your thoughts?
How does medical necessity get “overlooked” on the physician side as well as the inpatient side? Case managers, utilization review staff, physician advisors, CDI specialists, and coders, each carry out specific duties and responsibilities when reviewing medical records. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS, examines contributing factors and takes a closer look at guidelines Trailblazer Health recently issued defining specific joint replacement (DRG 470) documentation that both hospitals and physicians should follow to support medical necessity.
