Respondents to HCPro’s 2016 ICD-10 survey share their challenges and successes since implementation, while Monica Pappas, RHIA, and Darice M. Grzybowski, MA, RHIA, FAHIMA, offer their thoughts on the impact of ICD-10.
The Zika virus has become a major concern over the last couple months and new information about treatment and symptoms seems to emerge daily. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the latest information regarding the Zika virus and how coders can report it.
Since the dinosaurs roamed the earth (OK, since 1983), coding professionals have been tasked with ensuring that bills for Medicare patients included the proper elements of the diagnosis-related group (DRG) system so that the hospital got as much money as possible from Medicare.
The AHA's Coding Clinic for ICD-10-CM/PCS, Third Quarter 2015, opens with a discussion of the differences between excisional and non-excisional debridement‑diagnoses with a long history of coding and clinical documentation confusion.
Post-traumatic stress disorder isn’t only reported for military personnel. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about when PTSD may be reported and which diagnosis and procedures codes should be included.
Some interesting tidbits of information can be gleaned from the most recent release of the AHA Coding Clinic for ICD-10-CM/PCS to help coders as they work in the new code set.
The new ICD-10 system and its inherent errors, especially in ICD-10-PCS, has provided fertile ground for honest errors. But for this article, I'm going to talk about the other side of the coin, where new codes or descriptions of codes come out, often with inadequate definitions or directions, and people make up reasons to try to rook the system and bilk Medicare?that is, until enough caregivers get caught or advice comes out to squelch the "experts" who want to help you get denials by the hundreds or get hassled by Recovery Auditors.
Even before ICD-10, unclear definitions for certain diagnoses and procedures led to confusion for coders trying to interpret physician documentation. Robert S. Gold, MD, writes about conditions in the new code set that could lead to potential risks for providers.
Gwen S. Regenwether, BSN, RN, and Cheree A. Lueck, BSN, RN, discuss how the clinical documentation improvement department at their facility operates and their process for conducting a baseline audit and determining query rates across specialties.
Joel Moorhead, MD, PhD, CPC, writes about details for spinal conditions for coders to consider when choosing the most accurate ICD-10 codes for diagnoses and procedures.
Gwen S. Regenwether, BSN, RN, and Cheree A. Lueck, BSN, RN, look at how to use audit and query rate information to improve documentation at a facility and how to encourage continuing education and collaboration going forward.
Jennifer Avery, CCS, COC, CPC, CPC-I, writes about how the increased specificity in ICD-10-CM changes pregnancy coding and how to use gestational weeks in physician documentation to report trimesters.
I first attended a lecture on the "upcoming" ICD-10 changes that were expected in 1991 (when the rest of the world started transitioning). On October 1, 2015, a mere 24 years and countless lectures later, the U.S. finally adopted ICD-10 (via ICD-10-CM and PCS, which are both unique to the U.S. at this time).
Sometimes you see documentation in the medical record entered by one physician and then by nobody else. Sometimes you see documentation entered by one physician and copy/pasted by everyone else.
Before the new year begins, Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, recommends taking a look at post-implementation risks CMS and third-party payers have identified. She also offers solutions on auditing and reviewing these risks. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Once you have set up your free registration, you can log in and access this article by clicking here.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, reviews updates in Coding Clinic about coding orthopedic procedures in ICD-10-PCS, coma data in ICD-10-CM, and both cardiovascular procedures and diagnoses.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about how to report biopsies in ICD-10-PCS since the code set does not include the term among available root operations.
Nearly half a million patients receive dialysis services each year. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, writes about the ICD-10-CM and CPT® codes providers will need to know in order to report these services accurately.
CMS recently released an ICD-10-CM resource for specialties and specific conditions and services that collects varied educational tools, including webcasts, case studies, and clinical concept guides.
Q: How many times should Glasgow Coma Scale information be captured? If you have the ambulance, ED physician, and attending physician all recording the score, should each be reported?
Robert S. Gold, MD, reviews conditions such as sepsis, hypertension, and syncope and how the switch to ICD-10-CM clarifies reporting codes in some instances, while other issues from ICD-9-CM remain.
ICD-10 implementation has gone smoothly for approximately 80% of attendees who responded to a survey during a recent webcast from audit, tax, and advisory firm KPMG.
Some interesting tidbits of information can be gleaned from the most recent release of the AHA Coding Clinic for ICD-10-CM/PCS to help coders as they work in the new code set.
Q: A patient fractured all metatarsals last year and had open reduction and internal fixation. The patient now has a nonunion of the fracture sites and is going back to the OR for an amputation. What would be the appropriate ICD-10-CM seventh character to report?
Sherry Corsello, RHIT, CPC, writes about how to ensure consistency and reliability of records in ICD-10 and what providers can do with the more accurate data the code set will give them.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, answers questions from coders about OB diagnoses and procedures, including what’s bundled in the global package and how to report multiple births.
Extensive changes in ICD-10-CM terminology and codes for cardiovascular diseases often frustrate coders, says Cindy Basham, MHA, MSCCS, BSN, CCS, CPC . She provides an overview of the changes and notes what must be documented so coders can select the appropriate code.
ICD-10 may be a new system with thousands of additional codes compared to ICD-9-CM, but that doesn’t mean it can still accurately report every clinical scenario. Robert S. Gold, MD, identifies conditions that aren’t necessarily represented by the codes available.
After years of delays, industry and legislative pushback, and millions spent on technology upgrades and education, ICD-10 is finally here. Even though the fundamental process of coding and billing claims has not changed, providers will still need to pay close attention to their processes to keep the revenue cycle going and reduce denials.
After several delays, ICD-10 implementation is finally upon us. The healthcare industry has spent years planning, training, and testing?and now the moment we have all been waiting for has arrived. But don't breathe a sigh of relief just yet.
After several delays, ICD-10 implementation is finally upon us. The healthcare industry has spent years planning, training, and testing?and now the moment we have all been waiting for has arrived. But don't breathe a sigh of relief just yet.
I have been musing recently about things I've written for this journal over the past years. Hard to believe I've been doing monthly educational articles regarding the clinical aspects of coding since about 2002.
After several delays, ICD-10 implementation is finally upon us. The healthcare industry has spent years planning, training, and testing--and now the moment we have all been waiting for has arrived. But don't breathe a sigh of relief just yet.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about terms coders will see in physician documentation for ulcers and how to code related conditions in ICD-10-CM.
In addition to updated procedure codes in 2015, ICD-10-CM added new codes for reporting mammography and breast MRIs and ultrasounds. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, writes about how to identify which codes to use to meet Medicare requirements and where third-party payer requirements may diverge.
ICD-10 is undoubtedly affecting coder productivity, but Bonnie S. Cassidy, FAHIMA, RHIA, FHIMSS, CPUR, NAHQ, and Reid Conant, MD, FACEP, provide strategies for increasing proficiency and leveraging technology to reduce the effects of changing to a new code set.
When a patient suffers a traumatic injury or poisoning, we need to report how they became injured and where they were when it happened. You already know this from ICD-9-CM.
Sometimes people do their homework with setting up a new system, and sometimes they don't. Sometimes they do their homework, but not enough of it, and billions of dollars of wasteful spending occurs that could be avoided. But "they" won't listen.
Heart disease is the most common cause of death for both men and women in the U.S., according to the Centers for Disease Control and Prevention (CDC). The most common type is coronary artery disease (CAD), which can lead to heart attacks, heart failure, angina, and arrhythmias, according to the CDC.
Dual coding. Reformatting queries. Educating physicians. Let's face it?the to-do list for ICD-10 preparation is pretty long, and can be a bit daunting. With ICD-10 implementation happening this month, there's one thing your facility should do: prioritize.
Coders can no longer rely on the muscle memory and cheat sheets they developed working with ICD-9-CM for so long. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, reviews ways coders can update their processes for reporting certain OB/GYN services in ICD-10-CM.
Ready or not, ICD-10 is here. Sam Antonios, MD, FACP, FHM, CCDS, writes about how to talk to physicians about the transition in order to make it as seamless as possible.
The updated guidelines in ICD-10-CM will impact how coders report certain diagnoses. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, highlights important changes in each section for coders to review before implementation.
Sue Bowman, MJ, RHIA, CCS, FAHIMA, and Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, provide strategies for coders and coding department managers to speak with physicians regarding ICD-10 in order to allay physicians’ fears.
Combination codes in ICD-10-CM will allow coders to report pressure ulcer location and severity in a single code. Jaci Johnson Kipreos, CPC, CPMA, CEMC, COC, CPC-I, and Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD, review the stages of pressure ulcers and which information coders will have to look for in documentation.
ICD-10-CM seventh characters can be used to report more than just the episode of care. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, explains different seventh character uses and when to report them.
In ICD-10-CM, to tell the patient’s whole story, coders need to report external cause codes. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, explains the benefits of these codes and how to report them.
Every once in a while, another facility will send us a case to review and help them code. Here at the Fix ‘Em Up Clinic, we are happy to share our knowledge as we prepare for October 1. In that...
The expanded code set available in ICD-10-CM will give providers the chance to better tell the story of each patient’s care. Glenn Krauss , RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM, explains how coders can assist physicians in telling that story .
ICD-10 implementation is almost here, but coders are still facing resistance from physicians. W. Jeff Terry, MD, highlights ICD-10 challenges from the physician perspective, while Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, responds from a coder’s point of view.
Kids will soon be heading back to school here in Anytown, which also means the sports teams are holding preseason camps. And some of our local players practice a little too hard. Take Shaun, for...
The absolute best ICD-10 education is completely free, assuming you have an Internet connection. It will tell you everything you need to know about coding in ICD-10. What is this magical, mystical...
Armadillos apparently pose more hazards to your health than just passing on leprosy. A Texas man recently tried to shoot an armadillo three times and ended up being hit by his own bullet . He claims...
Hospitals did not get any ICD-10 relief as part of CMS’ accord with the AMA regarding a specificity grace period . However, they might not need much help, according to the latest Workgroup for...
Organizations have their hands full with ICD-10-CM implementation finally on the horizon. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, and AHIMA-approved ICD-10-CM/PCS trainer, examines how coding departments can clean up their processes now so they are ready for the new code set.
Coders may need to review the anatomy of the gastrointestinal system and disease processes for gallstones, hemorrhoids, and ulcerative colitis to choose the most specific ICD-10-CM code. Jaci Johnson Kipreos, CPC, CPMA, CEMC, COC, CPC-I, and Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, explain aspects of anatomy and what coders will need to look for in the documentation.
Bacteria are everywhere. Literally. And you can’t see them or feel them. In fact, trillions of them are living on your skin right now. So not all bacteria are bad. Some, though, can do nasty things...
Physician groups have led much of the resistance against ICD-10 implementation. At its June Delegates meeting, the AMA approved a resolution from W. Jeff Terry, MD, for a two-year grace period to protect physicians from errors and mistakes related to the code set. Terry also authored an AMA resolution to delay ICD-10 in November 2011, which led to postponing implementation until October 1, 2014.
We're less than four months away from the implementation of ICD-10-CM/PCS, and the AHA Coding Clinic for ICD-10-CM/PCS is rolling right along with advice for the new code set.
Alex comes in to see Dr. Guts complaining of fatigue and tiredness, as well as some slight abdominal pain. After performing a complete exam and blood tests, Dr. Guts diagnoses Alex with a bleeding...
CMS offered some clarity on what it considers to be a family of codes in ICD-10-CM. You might remember that CMS struck a deal with the American Medical Association (AMA) to get AMA on board with ICD-...
Leprosy cases are surging in Florida, with new cases in the first half of 2015 nearing the average total for an entire year. The potential source of this explosion (to use the term very loosely) of...
Joe comes into the Fix ‘Em Up Clinic to see Dr. Bones for a problem with his knee. Joe tells Dr. Bones that his right knee locks up occasionally and he often has pain in his knee. Joe denies any...
The gastrointestinal system is subject to many diseases and conditions that ICD-10-CM allows coders to report in more detail. Jaci Johnson Kipreos, CPC, CPMA, CEMC, COC, CPC-I, and Annie Boynton, BS, RHIT, CPCO, CCS, CPC, CCS-P, COC, CPC-P, CPC-I, describe the changes for reporting hernias and Crohn’s disease in ICD-10-CM.
Remember those friends and family cell phone plans where you didn’t use minutes if you called people in your circle? You had to pick who you wanted in your group and they had to pick you. It was very...
CMS and the American Medical Association (AMA) may have made peace regarding ICD-10, but it seems some members of Congress didn’t get the memo. Reps. Marsha Blackburn, R-Tenn., and Tom E. Price, R-Ga...
The optical system is the most complex organ system of the human body and is subject to specific disease processes. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer explains how to code some common eye diseases and treatments in ICD-10.
Alas, poor urosepsis. I knew him, Horatio, a condition of infinite vagueness. And thankfully, one ICD-10-CM is putting out to pasture. Now, if only the physicians would get on board. Physicians...
People do some strange things on vacation. I mean, really, really strange things. Take Mike, for example. Mike just returned from his European vacation and has come into the Fix ‘Em Up Clinic for a...
Betty Hovey, CPC, COC, CPB, CPMA, CPC-I, CPCD, and Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, review anatomy details of the heart and how to report ICD-10-CM codes for atherosclerosis and conduction disorders.
After a vigorous, last-ditch push by the AMA for a two-year transition period after implementation to protect physicians from all ICD-CM coding errors and mistakes, CMS and AMA made a joint...
The Fourth of July is in the books for another year and once again, we saw an interesting assortment of patients in the Fix ‘Em Up Clinic over the weekend. Let’s take a look at some of the more...
We’re officially three months (okay, 91 days) away from ICD-10 implementation, so you need to give your surgeons a quick introduction to ICD-10-PCS. Do NOT try to teach them to code. That’s not the...
Jurassic World is ruling the box office, so I thought I would use another blast from the past for the blog. Archeologists in Peru recently uncovered the skeleton of a teenage girl in a historic...
Richard came in to see Dr. Guts complaining of severe abdominal pain, nausea, vomiting, and blood in his stool. Dr. Guts sends Richard for a battery of tests and discovers Richard suffers from a...
How ready are you for ICD-10? The answer might depend on the type and size of your organization. Eighty-five percent of hospitals reported training staff on ICD-10, according to a recent eHealth...
Multiple surveys have shown that physician practices are lagging behind in preparation for ICD-10. CMS recently released a Quick Start Guide that outlines five steps healthcare professionals should...
Many organizations still lag in ICD-10 implementation, but it's not too late to prepare. Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS; Jean S. Clark, RHIA, CSHA; and Caroline Piselli, MBA, RN, FACHE, detail the steps organizations should take in order to be ready by October 1.
Cardiac conditions are some of the most common diagnoses seen in hospitals. Betty Hovey, CPC, COC, CPB, CPMA, CPC-I, CPCD, and Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, review coding conventions and documentation details for reporting heart failure and angina in ICD-10-CM.
The American Medical Association (AMA) is pushing for a two-year safe harbor for physicians so the doctors won’t be penalized for “errors, mistakes, and malfunctions relating to the transition.” That...
Mary decided to take advantage of a break in the rainy weather to head out and do some bird watching. The birds, however, were in no mood to be watched. Mary first came upon a warbler nest with four...
Sharme Brodie, RN, CCDS , highlights guidance on ICD-10-PCS root operations and seventh characters for ICD-10-CM from the latest issue of Coding Clinic .
Sometimes the logic of the American Medical Association (AMA) escapes me. Okay, most of the time, I have no idea what the people at the AMA are thinking. Take the organization’s continuing crusade to...
Rep. Gary Palmer, R-Alabama, doesn't want providers penalized for ICD-10 "errors, mistakes, and malfunctions relating to the transition" for two years after implementation. Unfortunately, it doesn't...
The Alabama state Senate passed a Joint Resolution urging Congress to delay the October 1, 2015 ICD-10 implementation. In and of itself, the resolution means very little. States cannot override the...
What is the correct ICD-9-CM code for pneumonia due to E. coli? A) 482.81 B) 482.82 C) 482.83 D) 482.84 Know the answer and want to be featured in the next issue of JustCoding News: Outpatient?...
Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, writes aboutwhat additional details coders will need to find in documentation to report pneumonia to the highest degree of specificity in ICD-10-CM and how to report it as a manifestation.
The American Medical Association (AMA) is trying to get a seat at the ICD-10 table by resolving to request inclusion as one of the Cooperating Parties. Mind you, today’s resolution at the AMA annual...
The AMA and Republican congressmen have been working together for quite a w hile to try and kill ICD-10, but their latest attempt shows not only desperation, but a fundamental misunderstanding of how...
We’re very excited to add a new voice to the ICD-10 Trainer blog family. I’ve (cough, cough) volunteered Steve Andrews to write for the blog. The joys of being the boss. Steve joined HCPro and...
One of the best parts of attending the Association of Clinical Documentation Improvement Specialists’ (ACDIS) 8 th Annual Conference is talking with others in the field to find out what documentation...
