Coding depends on clear and accurate documentation, especially with the added specificity available in ICD-10-CM. Andrea Clark-Rubinowitz, RHIA, CCS, CPCH , highlights tactics for improving provider documentationahead of implementation.
What constitutes good documentation? The next physician treating the patient should be able to pick up the medical record and know exactly what happened in the previous encounter. How often does this...
LOL BTW K+ BP↑ It’s a texting world, and more and more we use shorthand in our everyday lives. What about shorthand in a medical record? Can you code from it? First, let’s look at what kind of...
When a patient comes in contact with a drug or chemical that has an unhealthy effect, coders will have an easier time reporting it in ICD-10-CM than in ICD-9-CM. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer reviews poisoning and adverse effect coding in both code sets.
The section of codes that expanded most in ICD-10-CM involves orthopedic injuries, especially fractures. Kim Carr, RHIT, CCS, CDIP, CCDS , and Kristi Stanton, RHIT, CCS, CPC, CIRCC, highlight some of the most significant changes for fracture coding.
Take it from today’s victims, er, patients, at the Fix ‘Em Up Clinic: not every idea is a good idea. First in today is Jeff. He took part in a s’more eating contest at camp last night. I’ve...
ICD-10-CM includes 68,000 codes and ICD-10-PCS features 71,924 code choices. Scary numbers, right? Not according to Sue Bowman, RHIA, CCS, senior director of coding policy and compliance for AHIMA in...
The new ICD-10 implementation date gives us more than a year to finish preparing for the big transition. So why learn about how to code diabetes in ICD-10-CM now? “It’s never too early to start...
The summer heat can lead to an increase in many sun and heat-related illnesses. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, reviews common summer ailments and how to choose the right codes in ICD-9-CM and ICD-10-CM.
Well, we once again have an official ICD-10 implementation date. HHS released a display copy of Administrative Simplification: Change to the Compliance Date for the International Classification of...
Coders have only two options for reporting fractures of the patella in ICD-9-CM, closed (822.0) and open (822.1). In ICD-10-CM, that number will jump to more than 400. Many of these options are the result of separate codes to denote laterality (right or left) in ICD-10-CM. However, the code set also includes options for specific types of fractures, increasing the importance of clear and accurate provider documentation.
In ICD-10-CM, you need to communicate with the medical staff about the specific elements that are important for pathologic fractures, because the coding is different than it used to be and it's so different from traumatic fractures.
We were expecting October 1, 2015, to be the new ICD-10 compliance date and CMS made it official with the release of a final rule, Administrative Simplification: Change to the Compliance Date for the...
Ah, the joys of camping. The fresh air, the beautiful scenery, the friendly forest creatures. Sounds like a great way to escape from the urban jungle and the daily grind. Nice in theory, not so nice...
Coders use different codes to report traumatic and pathologic fractures. Robert S. Gold, MD, and Kristi Stanton, RHIT, CCS, CPC, CIRCC, highlight the differences in coding for the two etiologies of fractures in both ICD-9-CM and ICD-10-CM.
Inpatient coders and clinical documentation improvement specialists are very familiar with CCs and MCCs. After all, they help determine the MS-DRG assignment for a particular inpatient stay. ICD-10-...
Put on your deerstalker hat and grab your magnifying glass. It’s time to do our best Sherlock Holmes impersonation. We just received a chart from Dr. Doolittle and we need to code the procedure...
Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, details correct coding for spinal injuries in both ICD-9-CM and ICD-10-CM, along with the documentation requirements for choosing the most accurate code.
Julie comes into the Fix ‘Em Up Clinic with a seriously broken arm. Her son Jay left his toy fire engine on the stairs and Julie tripped over it. She threw her arms out to brace her fall. And then...
Have you started dual coding for ICD-9 and ICD-10? Two facilities shared their experiences today during the AHA’s webinar, Lessons Learned on Dual Coding–A Provider’s View. The first thing you need...
It turns out that not all eponyms are going away in ICD-10-PCS. The Alphabetic Index still includes an entry for a Roux-en-Y operation. The entry directs you to see bypass of the gastrointestinal...
Body mass index (BMI) reporting is becoming more important as a diagnostic tool for providers, and ICD-10-CM will expand the ability to accurately report it. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , looks at documentation concerns and coding concepts for BMI in both ICD-9-CM and ICD-10-CM.
ICD-10-CM expands the coding options for phobias, eating disorders, and pervasive developmental disorders. Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD , reviews these disorders and how to report them in ICD-10-CM.
Holly spent the weekend hanging out at the beach, enjoying the sun. The sand was so warm that she slipped off her shoes to stroll near the water. And disturbed a crab in the process. The crustacean,...
A lot of people are starting their Fourth of July celebrations early. At least it seems that way at the Fix ‘Em Up Clinic. Shannon took her dog Damian to the park to watch some fireworks last night...
Go to your local bookstore, pick up a copy of Gray’s Anatomy (the book, not the television show), and flip though the illustrations. Alternately, you can Google “Gray’s anatomy illustrations.” They...
Editor's note: With the increased specificity required for ICD-10-CM coding, coders need a solid foundation in anatomy and physiology. To help coders prepare for the upcoming transition, we will provide an occasional article about specific anatomical locations and body parts as part of a larger series for ICD-10-CM preparation. This month's column addresses the anatomy of the feet.
CMS and Obamacare have increasingly been moving healthcare toward a more value-based model. They want to pay physicians for how well they treat patients and not by the volume of services they provide...
More healthcare providers would have been ready for an October 1, 2014 ICD-10 implementation date than people may have realized, according to a survey by Edifecs, eHealth Initiative (eHI) and AHIMA...
Composers lead pretty safe lives, right? They compose music, conduct the symphony, and hang out at post-show parties. And we’re not talking rock star parties. Sometimes, though, that job isn’t so...
Poor Finn is having a rough week. It started out well as he spent Sunday with his folks and older brother at an amusement park being as amused as a 6-month-old can be. Things started going downhill...
Jeff comes in to the Fix ‘Em Up Clinic complaining of shortness of breath, a persistent cough, tightness in his chest, and frequent respiratory infections. He tells Nurse Nosey that he smokes a pack...
Dodge ball is not a game for wimps or the uncoordinated. Even master ball dodgers can end up in the Fix ‘Em Up Clinic. Steve engaged in a spirited game of dodge ball over the weekend, which resulted...
What do you get when you combine a full moon and Friday the 13th? Some really odd injuries at the Fix ‘Em Up Clinic. Fortunately, we here at the clinic suffer from neither paraskevidekatriaphobia (...
I recently spoke with Barbara Hinkle-Azzara, RHIA , vice president of HIM operations for HRS Coding in Baltimore about preparing for ICD-10 and, more specifically, about the anticipated MS-DRG...
A patient comes into the ED following an automobile accident. The physician documents that the patient has an open, displaced fracture of the lateral condyle of the right tibia. The physician also...
We all know that ICD-10 codes will require more complete documentation. We’ve been telling physicians that, but maybe we’re not explaining it well or correctly. What makes documentation better? It’s...
The April 1 confirmation of the delay in implementing the ICD-10 code set until at least October 1, 2015, certainly took the wind out of many healthcare organizations' sails.
If you’ve glanced through the ICD-10-CM Manual, you likely noticed all of the codes for fractures, strains, and dislocations. We’re going to have a lot more choices in ICD-10-CM, which means we’re...
Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD , looks at common dermatology conditions, including non-pressure chronic ulcers and psoriasis, as well as new concepts coders will need to look for to report these conditions in ICD-10-CM.
Ah, Memorial Day, the unofficial start of summer. And the day after Memorial Day is the unofficial start of summer injury season at Fix ’Em Up Clinic. Jackee took advantage of the long weekend by...
Some conditions, such as gangrene due to diabetes, require two codes to correctly report in ICD-9-CM. In ICD-10-CM, coders will only need one code. Jennifer Avery, CCS, CPC-H, CPC, CPC-I, and William E. Haik, MD, FCCP, CDIP, explain how these combination codes act as their own CC or MCC in ICD-10-CM.
Coders can only use the documentation they have to code in ICD-9-CM and ICD-10-CM. Adelaide La Rosa, RN, BSN, CCDS, and Deborah Lantz, RHIA, discuss the importance of good documentation when coding for fractures and congestive heart failure in both systems.
Recently I have seen many articles casting a negative outlook on ICD-10. They scare everyone into believing that added specificity to the codes will create more work for everyone, especially the...
