Katy Good, RN, BSN, CCDS, CCS, Paul Evans, RHIA, CCS, CCS-P, CCDS, Laurie Prescott, MSN, RN, CCDS, and Gloryanne Bryant, BS, RHIA, CDIP, CCS, CCDS, all comment on how over-querying is a common concern in clinical document improvement, and how over-querying can cause delays in documentation and coding processes.
The FY 2017 IPPS proposed rule addresses MS-DRG classifications and relative weights pertaining to the categories of other cardiothoracic procedures without MCC, and injuries, poisonings and toxic effects of drugs.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, reviews scenarios for initial, subsequent, and sequela encounters, and helps coders better understand how to assign seventh characters for each type of encounter. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, discusses strategies for reporting, and better understanding, pyeloplasty in ICD-10-PCS. Note: To access this free article, make sure you first register if you do not have a paid subscription.
ICD-10-PCS defines the root operations in very specific ways and coders need to know the definitions and the nuances of the root operations. Learn more about root operations that involve the physician looking at a patient, Inspection and Map.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, writes about key details in documentation that coders will need to look for in order to report procedures using the root operation Dilation.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , and AHIMA-approved ICD-10-CM/PCS trainer, writes that reporting imaging, nuclear medicine, and radiation therapy procedures will dramatically change depending upon whether the patient has been admitted into a hospital or is being cared for as an outpatient
Root operations are the fundamental building block of ICD-10-PCS codes, but providers may not use the same terminology coders are familiar with. Review these root operations that involve taking out all or some of a body part.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, reviews anatomic details related to hernias and how to use operative report details to report the appropriate procedure codes for hernia surgeries.
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.
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.
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.
Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV) site used have to come from the physician in the progress note or can this particular information be extrapolated from nursing notes, orders, etc.? As far as I can tell, a blood transfusion is usually administered to whatever peripheral IV line/site is available, unless otherwise contraindicated or instructed differently by a specific physician order.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about the section added to ICD-10-PCS for 2016 for reporting new technology procedures.
Jillian Harrington, MHA, CCS, CCS-P, CPC, CPC-P, CPC-I, MHP, reviews the components in operative reports coders will need to find in order to report ICD-10-PCS codes for spinal fusions.
Queries will no doubt increase due to the increased specificity in ICD-10-PCS. John C. Alexander Jr., MD, MBA, James Fee, MD, CCS, CCDS, and George W. Wood II, MD, offer insight into which specialties will be most impacted and how coders can talk to surgeons about the query process.
Coders will need to master root operations in order to be successful in ICD-10-PCS. Cindy Basham, MHA, MSCCS, BSN, CCS, CPC, writes about which root operations will be most frequently used for cardiovascular procedures and how to interpret the guidelines related to them.
Six ICD-10-PCS root operations require a device, including Revision, Replacement, and Removal. Gretchen Young-Charles, RHIA, and Anita Rapier, RHIT, CCS, review how to differentiate these root operations and report associated devices.
