Ask a physician why he or she documents in the medical record and you'll get a variety of answers. Some physicians will say they document because the medical records people hound them for the information, or they do it so they get paid. They may also say they do it to complete the medical record.
Many organizations still lag in ICD-10 implementation, but it's not too late to prepare. Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS; Jean S. Clark, RHIA, CSHA; and Caroline Piselli, MBA, RN, FACHE, detail the steps organizations should take in order to be ready by October 1.
Taxonomy codes play a very important role in medical billing and credentialing for providers or group specialties.HIPAA-standard code sets specify a "standard" for transactions. In many cases, a taxonomy code is required to reimburse a claim; however, the reporting requirements for a taxonomy code may vary between insurance carriers and your third-party payers.
PSI 7 evaluates the hospital’s risk-adjusted rate of central venous catheter-related bloodstream infections. Shannon Newell, RHIA, CCS, Steve Weichhand , and Sean Johnson explain inclusions, exclusions, and risk adjustment factors for this measure.
When providers use different definitions for the same disease, confusion and chaos result. Trey La Charité, MD , discusses how coding and clinical documentation improvement specialists can clear up the situation.
PSI 15 measures the hospital’s risk-adjusted rate of accidental punctures and lacerations. Shannon Newell, RHIA, CCS, Steve Weichhand , and Sean Johnson explain inclusions, exclusions, and risk adjustment factors for this measure.
Coders and clinical documentation specialists can use queries to improve physician documentation of a patient’s severity of illness and risk of mortality. Rhonda Peppers, RN, BS, CCDS, and Sara Baine, MSN-Ed, CCDS, walk through a case study to highlight query opportunities.
Our sister website JustCoding.com recently published its 2014 Coder Salary Survey. Since many of our readers responded to the survey, we would like to share some of the results with you.
Coronary artery disease (CAD) develops when the arteries that supply the blood to the heart muscles become hardened and narrowed due to a buildup of cholesterol and other materials, such as plaque, on their inner wall. It's also called atherosclerosis.
A hiatus from Recovery Auditor scrutiny may have allowed HIM professionals to focus on other issues, but Laura Legg, RHIT, CCS, explores why HIM departments need to gear up for Recovery Auditors’ return.
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.
We've compiled the numbers from the latest JustCoding Salary Survey and now you can see how you compare to the average coder in terms of salary, experience, and other factors. Monica Lenahan, CCS, and Susan E. Garrison, CHCA, CHCAS, CHC, CCS-P, CPC, CPC-H , analyze the results and discuss the future of coder salary and responsibilities.
In the first part of a two-part series, Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, discusses the use of Z codes in ICD-10-CM.
With quarterly code updates and other regulatory changes from CMS throughout the year, the chargemaster coordinator has to constantly monitor the healthcare landscape, but the final few months of the year remain the most challenging.
Coders often talk about guidelines and coding conventions, but what about ethics? Robert S. Gold, MD , discusses the value of following ethical coding standards.
CMS designates a certain set of procedures as inpatient-only, meaning it will only reimburse facilities for these procedures when they are performed in the inpatient setting. Inpatient-only procedures present numerous problems for hospitals.
In part 2 of his series on medical necessity and coding, Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, examines medical necessity and the 2-midnight rule using a case study.
The Official ICD-9-CM Guidelines for Coding and Reporting talk about the perinatal and newborn period as being the first 28 days of life. Robert S. Gold, MD, explains when neonatal really is—and isn’t—neonatal.
Coders now incorporate consideration of medical necessity when coding for inpatient admissions. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI , explains the importance of understanding the concept of medical necessity as it relates to coding.
The complexity of coding rules and the quality of documentation in facilities sometimes make correct DRG assignment a daunting task. Laura Legg, RHIT, CCS, highlights current DRGs that are subject to Recovery Auditor scrutiny and provides tips for accurate DRG assignment.
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.
CMS' introduction of the 2-midnight rule in the 2014 IPPS final rule makes properly identifying inpatient-only procedures even more important for hospitals.
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.
CMS' 2015 IPPS proposed rule, released April 30, focuses on quality measures, such as HAC reduction, readmissions reduction, and hospital value-based purchasing (VBP) programs.
Healthcare facilities are subjected to a myriad of auditorswho scrutinize everything from how many units of a drug were billed to whether or not a patient actually needed to be admitted to the hospital. Trey La Charité, MD , explains how to turn every denial into a learning experience.
Plenty of uncertainty surrounds the ICD-10 implementation delay, but healthcare organizations shouldn’t put the brakes on their plans. Cheryl Ericson, MS, RN, CCDS, CDIP , William E. Haik, MD, FCCP, CDIP , Monica Lenahan, CCS , Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and James S. Kennedy, MD, CCS, CDIP, offer thoughts on how to keep moving forward with ICD-10.
In an ideal world, all coders and CDI specialists would get along well and work together with minimal conflict. No one is going to agree all of the time, nor should they. A healthy, respectful dialogue can lead to a better understanding of the patient's clinical condition and result in more accurately coded records.
You all know that I have been unhappy with some code definitions in ICD-9 and have ucceeded in getting some changes made in ICD-9 and ICD-10-CM code sets.
Inpatient coders will have a new coding system on October 1, but they won’t have to learn new MS-DRGs. They aren’t changing. However, coders will see some shift in MS-DRG assignment in ICD-10. Donna M. Smith, RHIA, and Lori P. Jayne, RHIA, reveal why the MS-DRG shifts will occur.
Whether you work in a dedicated children’s hospital or a general hospital with a pediatric service line, you will likely come into contact with coding charts of kids. Sometimes they are easy (e.g., an inguinal hernia repair without obstruction or gangrene is an inguinal hernia repair without obstruction or gangrene—except it has to be identified as right or left in ICD-10). Sometimes they are not so easy (e.g., complex congenital diseases and their manifestations and complications).
With the ICD-10-CM implementation date approaching, training and retaining staff that knows the new system is paramount for coding departments. Sabita Ramnarace, MS, RHIA, CCS, CHP , and Rudy Braccili, Jr., MBA, CPAM, review strategies that can help providers develop retention plans in their organization.
Drug-resistant bugs are becoming more common as antibiotic use increases. Shelley C. Safian, PhD, CPC-H, CPC-I, CCS-P , AHIMA-approved ICD-10-CM/PCS trainer, explains why and how microbes become antibiotic resistant and compares ICD-9-CM and ICD-10-CM coding for these infections.
Different studies using different methodologies all point to the same conclusion: Coder productivity will decrease after the switch to ICD-10. However, no one knows what will happen to coding accuracy.
In order to report accurate evaluation and management codes, coders need accurate, complete documentation. Coders can play a critical role in ensuring proper documentation. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, looks at methods coders can use to promote better documentation.
The audit landscape continues to change as Recovery Auditors expand prepayment reviews and CMS implements its new 2-midnight rule. Debbie Mackaman, RHIA, CPCO, Ralph Wuebker, MD, MBA, and Kimberly Hoy Baker, JD, review some of the recent changes to audit focus areas.
Physicians are never going to like receiving queries from coders and CDI specialists. They really won't like all the queries they will receive after the transition to ICD-10.
The Cooperating Parties made the last regular update to the ICD-9-CM codes October 1, 2011, but they are still adding codes for new technologies each year. The updates are considerably smaller than the regular updates, but coders still need to be aware of them.
The ICD-10 implementation will result in a slowdown at every level of coding. Elaine O’Bleness, MBA, RHIA, CHP, Migdalia Hernandez, RHIT, Kimberly Carr, RHIT, CCS, CDIP, and Rachel Chebeleu, MBA, RHIA, provide suggestions on how to minimize that productivity decline.
How well could you code in ICD-10 using your current physician documentation? Do your physicians document the specificity and detail coders need to select the correct ICD-10-PCS code? Do your physicians document laterality, which coders will need for many ICD-10-CM codes?
