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.
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.
ICD-10 implementation will arrive very soon, and many facilities are putting the final touches on their preparations. In the rush to complete coding education, documentation improvement, and system updates, HIM managers may not have looked at looming MS-DRG shifts.
ICD-10-PCS will completely change the way coders report inpatient procedures. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA, reveal potential trouble spots for the new coding system.
The only difference between ICD-10-PCS root operations Excision and Resection is the amount of the body part removed. Jennifer Avery, CCS, COC, CPC, CPC-I, Anita Rapier, RHIT, CCS, and Cheree Lueck, BSN, RN, provide tips for determining the correct root operation.
Drainage procedures can be therapeutic in nature or diagnostic, such as when a physician removes a fluid or gas for biopsy. A nita Rapier, RHIT, CCS, Nelly Leon-Chisen, RHIA, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS , highlight the differences in coding diagnostic and therapeutic thoracocentesis and lumbar tap procedures in ICD-10-PCS.
ICD-10-PCS root operations Excision and Resection differ only in how much of a body part is removed. Review these situations to clarify which root operation to report.
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.
The Cooperating Parties added a 17th section to the ICD-10-PCS Manual for 2016: Section X (New Technology). Pat Brooks, RHIA, and Rhonda Butler, CCS, CCS-P, highlight how and when to use codes in this new section.
The AHA’s Coding Clinic for ICD-10 continues to provide updates and guidance for a variety of inpatient procedures, both routine and not so routine. J ames S. Kennedy, MD, CCS, CDIP, Anita Rapier, RHIT, CCS, and Sharme Brodie, RN, CCDS, highlight some important advice from Coding Clinic.
ICD-10-PCS root operations Drainage, Extirpation, and Fragmentation involve removing material from the body, but in different ways. A nita Rapier, RHIT, CCS, Kristi Stanton, RHIT, CCS, CPC, and James Fee, MD, CCS, CCDS, offer tips for distinguishing between the root operations.
With fewer than 100 days until ICD-10-CM/PCS implementation, plenty of questions still remain about ICD-10-PCS coding. The AHA's Coding Clinic for ICD-10 continues to provide updates and guidance for a variety of inpatient procedures, both routine and not so routine. We examine some of that guidance in this article.
ICD-10-PCS does not include unspecified options so coders will need information for each of the seventh characters in the code. Cheryl Ericson, MS, RN, CCDS, CDIP, and Lynn Salois, RHIT, CCS, CDIP, review some of the areas where a surgical query might be needed.
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 .
ICD-10-CM will still allow coders to report unspecified codes. However, coders will not have that option in ICD-10-PCS. Every character has to have a value, which will lead to an increase in surgical queries.
Percutaneous transluminal coronary angioplasty (PTCA) is a minimally invasive procedure to open up blocked coronary arteries. Laura Legg, RHIT, CCS, AHIMA-approved ICD-10-CM/PCS trainer, Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, and Sara Clark, RHIA, MLS, AHIMA-approved ICD-10-CM/PCS trainer, explain how coders will report PTCA in ICD-10-PCS.
The ICD-10-PCS Manual includes 17 different sections, including Administration. Learn how to assign codes from this section to prepare for ICD-10-PCS implementation.
Coronary artery bypass graft procedures are not the only ones coders will report using the root operation Bypass in ICD-10-PCS. Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, and Lisa Crow, MBA, RHIA, explain how to code for other bypass procedures in ICD-10-PCS.
Many coders and CDI specialists memorized previous Official Guidelines for Coding and Reporting , Coding Clinic for ICD-9-CM and do not have to give them a lot of forethought before applying correctly to their day-to-day reviews. Although many of the Official Guidelines for Coding and Reporting remain the same in ICD-10, none of Coding Clinic's previous advice can be applied to the new code set. Without years of new Coding Clinic advice under their belts, it may take some time before the staff exhibits the same ease when applying ICD-10-CM/PCS codes to the documentation provided.
ICD-10 implementation requires organizational coordination from a variety of departments. Chloe Phillips, MHA, RHIA, and Kayce Dover, MSHI, RHIA, discuss how organizations can overcome challenges regarding staffing, productivity, and data analytics as they prepare for the change.
Despite all the uncertainty surrounding the implementation of ICD-10-CM/PCS, the Cooperating Parties (i.e., the American Hospital Association, AHIMA, CMS, and the National Center for Healthcare Statistics) nevertheless decided that the farewell issue of Coding Clinic for ICD-9-CM (which was published in the first quarter of 2014) will remain the farewell issue.
Coronary artery bypass graft (CABG) procedures are not the only ones coders will report using the root operation Bypass in ICD-10-PCS. Surgeons can create bypasses in other vessels of the body.
The anatomical definition of a body part may not be the same as the ICD-10-PCS identification of a body part. Jennifer Avery, CCS, CPC-H, CPC, CPC-I, Nena Scott, MSEd, RHIA, CCS, CCS-P, and Gretchen Young-Charles, RHIA, explain the guidelines for selecting the appropriate body part and how body parts can affect root operation selection.
The ICD-10 implementation delay mandated by Congress this spring granted providers an extra year to prepare their coders and clinicians on the requirements of the new code set, but a recent survey has found some organizations heading in the wrong direction.
Coders need to understand the different approaches for procedures in ICD-10-PCS because they're required and the new system does not include default or unspecified options. Laura Legg, RHIT, CCS, Nena Scott, MS, RHIA, CCS, CCS-P, and Gretchen Young-Charles, RHIA, explain the different approaches and address gray areas for selecting the most appropriate character.
ICD-10-PCS codes consist of seven characters, each of which identifies a unique, specific piece of information. For most of the codes in the Medical and Surgical section, each character represents the same information every time.
When a physician closes off varices, coders must determine the location and method the physician used to correctly build an ICD-10-PCS code. Nena Scott, MSEd, RHIA, CCS, CCS-P, and Gretchen Young-Charles, RHIA, review the components of different procedures for closing off varices and how to code those procedures in ICD-10-PCS.
ICD-10 implementation and coding present plenty of challenges, especially when it comes to ICD-10-PCS. Sue Bowman, RHIA, CCS, and Donna Smith, RHIA, clear up some misconceptions about ICD-10 implementation and use.
If coders choose the wrong root operation in ICD-10-PCS, they will arrive at an incorrect code. Nena Scott, MSEd, RHIA, CCS, CCS-P, AHIMA-approved ICD-10-CM/PCS trainer, Gretchen Young-Charles, RHIA, Anita Rapier, RHIT, CCS, and Nelly Leon-Chisen, RHIA, discuss some of the root operation clarifications offered by Coding Clinic .
ICD-10-PCS root operations Control and Repair are used when a procedure doesn’t really fit into a different root operation. Nena Scott, MSEd, RHIA, CCS, CCS-P, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS , discuss when coders should use these two root operations.
ICD-10 implementation and coding present plenty of challenges, especially when it comes to ICD-10-PCS. Plenty of myths are also floating around and some of them fairly prevalent. One way to make sure the most recent ICD-10 implementation delay is the last ICD-10 implementation delay is to bust some of these myths.
ICD-10-PCS requires coders to possess strong clinical knowledge as well as a solid foundation in anatomy and physiology. Coders need to understand what physicians are actually doing in certain...
ICD-10-PCS includes three root operations that involve taking out or eliminating solid matter, fluids, or gases from a body part. Donna Smith, RHIA, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, review root operations Drainage, Extirpation, and Fragmentation.
Hospitals will still use CPT ® codes to report procedures after ICD-10 is implemented, but some will also code with ICD-10-PCS. Andrea Clark, RHIA, CCS, CPC-H , reviews the advantages and challenges outpatient facilities may face when using ICD-10-PCS.
"Sometimes the questions are complicated and the answers are simple." ?Dr. Seuss This quote seemed an appropriate way to begin a discussion about outpatient encounters and ICD-10-PCS. You see, outpatient procedures will still be coded using CPT ® /HCPCS?the HIPAA-approved code set for reporting hospital outpatient procedures?regardless of when ICD-10 is implemented.
Q: A patient comes into the ED with sickle cell crisis and is in a lot of pain. The physician states the patient needed “aggressive” pain control for treatment, because what was given in the beginning provided only minimal relief. Could I code using CPT ® code 99285 (ED visit for evaluation and management of a patient, including a comprehensive history, comprehensive exam, and high complexity medical decision making)?
ICD-10-PCS will be a big change for inpatient coders. The best way to learn the new coding system is to practice, practice, practice. See how well you know ICD-10-PCS by assigning all applicable ICD-10-PCS codes for the following case.
Learning to code in ICD-10-PCS is in some respects like learning a language, you need a strong foundation in the rules. Sue Bowman, MJ, RHIA, CCS, FAHIMA , Gerri Walk, CCS-P , Nena Scott, MSEd, RHIA, CCS, CCS-P , and Jennifer Avery, CCS, CPC-H, CPC, CPC-I, discuss the guidelines related to root operations in ICD-10-PCS.
Both knee and shoulder replacement procedures include devices and fall under the ICD-10-PCS root operation Replacement (R). Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, and Nena Scott, MSEd, RHIA, CCS, CCS-P , review the definition of a device in ICD-10-PCS and review how to code for shoulder and knee replacements.
