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.
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.
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.
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.
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).
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.
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: 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.
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.
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.
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.
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 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.
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.
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.
