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.
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.
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.
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.
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.
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).
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.
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?
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.
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.
