Services provided in an inpatient setting are reported using two different coding systems. The facility reports procedures using ICD-10-PCS codes while the individuals providing the care report professional services using CPT codes. Terry Tropin, MSHAI, RHIA, CCS-P, provides a glimpse into how these two coding systems can work together in order to fully report inpatient services.
Comorbid conditions or complications (CC) and major comorbid conditions or complications (MCC) indicate a higher level of severity of illness, an elevated risk of mortality, and an above average intensity of resource utilization. Given their impact on reimbursement and quality reporting, Nancy Reading, BS, CPC, CPC-P, CPC-I, emphasizes how success in coding CCs and MCCs requires a delicate balance of documentation specificity and clinical clarity in diagnosis assignment.
Our experts answer questions on navigating sepsis coding in an era of conflicting clinical criteria, evaluating abnormal renal function in the clinical record, and addressing payer denials that passed on queries.
Kelly Rice, MSHI, BSN, RN, CCDS, CDIP, CCS, CRC, details how to differentiate and document between acute pulmonary insufficiency following surgery and acute respiratory failure following surgery. Identifying and discussing common clinical indicators for these diagnoses can help support documentation integrity efforts, reduced denials, and the inappropriate triggering of PSIs.
Assigning and sequencing diagnosis codes for COPD in the face of an acute exacerbation of COPD, particularly when the patient’s condition progresses to respiratory failure, has posed challenges to coders for quite a while. Nancy Reading, BS, CPC, CPC-P, CPC-I, demonstrates how to nail down the diagnosis codes based on clinical presentations before determining the correct sequencing for principal diagnosis assignment.
Hospitals are seeing an increasing number of clinical validation denials that are frequently linked to documentation that does not fully describe the clinical severity of the patient’s condition, even though the documentation technically meets coding requirements. One helpful way to approach this issue is by recognizing inpatient severity drivers—such as physiological instability, organ dysfunction, and treatment intensity—in order to understand the true severity of illness in hospitalized patients.
Our experts answer questions on assigning ICD-10-CM P codes versus Z codes for newborn conditions, using artificial intelligence to improve documentation and coding workflows, and coding postsurgical malabsorption.
Imaging services are used by healthcare professionals to provide a non-invasive way of looking inside the human body. For coders, piecing together ICD-10-PCS codes to report the imaging services involves understanding the unique structure of the Imaging section and applying the correct characters to reflect the procedure performed. Follow Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , as she delves into the section.
For the 10 years we have been working with the ICD-10-PCS code set, these codes, used to report procedures provided to an inpatient, have required seven characters. Each character reports a very specific element of the service provided. Here, Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, is going to focus on character 6 for Device.
Accurate procedure code assignment requires coders to have a good understanding of coding guidelines, anatomy, physiology, and medical terminology, as well as the ability to decipher the operative report. Assigning ICD-10-PCS codes for pacemaker insertions requires all these skills and more in some cases. Teresa Seville, RHIT, CCS , justifies how understanding the types of pacemakers and where they are inserted is paramount for correct coding.
