Physicians often use the acronyms IBS (which should indicate irritable bowel syndrome) and IBD (which should indicate inflammatory bowel disease) interchangeably even though they represent completely different conditions with different treatment and prognoses.
Emergency Departments (EDs) see a wide range of illnesses and injuries, from minor to major, which may require critical care. Lois E. Mazza, CPC, details how critical care is defined, what elements providers must document, and under what circumstances critical care can be coded for ED patients.
Do not view the proposed rule extending the ICD-10 implementation date from October 1, 2013, to October 1, 2014, as a year-long break from ICD-10 preparations. Rather, focus on using the additional time allotted to your advantage. This includes conducting documentation and coding assessments to gauge ICD-10 readiness. Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, explains why—and how—facilities should start assessing the readiness of their coding staff and documentation procedures in relation to ICD-10 requirements and create strategies to manage any deficiencies.
Coders and clinicians often seem to speak different languages. What a clinician considers important information may not be what a coder needs to assign the correct code. Clinicians may not document a piece of information that is vital to the coder. Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, Joseph Nichols, MD, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, explain how clinicians and coders can work together to improve communication.
These days, documentation improvement and compliance are at the forefront of coders' minds. In some cases, coders are led completely astray by bad data and physician documentation that isn't entirely accurate. Robert S. Gold, MD, emphasizes that it’s important for coders to always look at the larger clinical picture in the medical record—not just a documented laboratory result or change in vital sign. Gold applies this philosophy and examines a number of conditions, including anemia, acute kidney injury, congestive heart failure, and myocardial infarction.
Coders are constantly analyzing documentation for clues and details that may indicate the need for a physician query. For example, coders should watch for clinical evidence that points to a condition that the physician may not have explicitly documented. Coders also need to be wary of reporting conditions without accounting for context or other clinical indicators in the documentation. William E. Haik, MD, CDIP, explains how this can lead to inappropriate reporting of an MCC, for example, that the overall clinical picture does not support.
How does medical necessity get “overlooked” on the physician side as well as the inpatient side? Case managers, utilization review staff, physician advisors, CDI specialists, and coders, each carry out specific duties and responsibilities when reviewing medical records. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, CCDS, examines contributing factors and takes a closer look at guidelines Trailblazer Health recently issued defining specific joint replacement (DRG 470) documentation that both hospitals and physicians should follow to support medical necessity.
Can you begin to imagine how complex a piece of great literature would be if we had to include complete documentation of each medical incident? Or have to stop every time we have to develop physician...
Even if you didn’t make a personal New Year's resolution, you should make a professional one: to be more conscientious when scrutinizing physician documentation. Experts say every coder should scrutinize physician documentation, especially with ICD-10-CM/PCS looming on the horizon. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, and Dinh Nguyen examine the role coders play in determining diagnosis quality and accuracy.
The task of assigning the appropriate present on admission (POA) indicator for various conditions is still fraught with a number of challenges—many of which stem from problems coders have in obtaining clear, explicit physician documentation. Colleen Stukenberg, MSN, RN, CCDS, CMSRN, and Donna D. Wilson, RHIA, CCS, CCDS, discuss how gleaning the necessary details from the records can be a daunting task in and of itself, and then inconsistencies among various physicians makes assigning POA indicators that much harder.