The shift from fee-for-service to value-based programs for outpatient payment systems has increased the need for outpatient CDI staff to review documentation for pertinent clinical factors.
With the expansion of telehealth services, providers for both the originating site and distant site can also count on the expansion of Medicare contractor audits.
Stress urinary incontinence is a common problem induced by minor physical stressors such as laughing, coughing, or sneezing. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , writes about CPT coding for procedures such as sling operations and laparoscopies, used to treat urinary stress incontinence.
Even experienced coding professionals find injection and infusion coding confusing because CPT guidelines for these services differ from the guidelines for most other services. Review the drug administration hierarchy and guidelines for reporting therapeutic, prophylactic, and diagnostic injections and infusions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Wound care coding can be challenging as wound size, depth, and severity must be properly documented to report the most accurate codes. Review coding for pressure ulcers in ICD-10-CM and wound debridement in CPT to avoid common documentation and reporting errors. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS , writes about discussions at the 2017 AMA CPT Symposium that could impact coders, including issues with the Table of Risk for E/M office visit codes and suggestions for E/M guideline revisions. This article is part two in a series.
In the 2018 OPPS final rule, CMS finalized a change to the current clinical laboratory date of service policies for outpatient molecular pathology tests and advanced diagnostic laboratory tests.
One of the most memorable sessions at the AMA CPT Symposium in November 2017 involved an impromptu open mic feedback session facilitated by CMS’ Marge Watchorn, deputy director of the Division of Practitioner Services. The focus of this session was the applicability of the current CMS documentation guidelines for E/M services.
The skin is the largest organ in the human body and plays a vital role in protecting the body from injury and illness. This article reviews integumentary anatomy and provides guidance to aid in accurate ICD-10-CM and CPT code assignment for complex integumentary diagnoses and procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS , writes about discussions at the AMA CPT Symposium that could impact coders, including the need for updates to CMS’ E/M Documentation Guidelines and how medical decision making is used as a key component for E/M reporting.
CPT modifier -22 for an increased procedural service is frequently reported incorrectly. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , describes the circumstances under which it would be appropriate to report modifier -22, and provides tips for accurate documentation to support use of the modifier.
CMS' Bundled Payments for Care Improvement Advanced model will qualify as an Advanced Alternative Payment Model under the Quality Payment Program and include outpatient episodes.
Updates to the 2018 CPT Manual particularly effect coding for cardiovascular and laboratory procedures. Stay-up-to-date with these changes and take time to understand complex procedures to prevent interruptions to claims processing. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
New ICD-10-CM/PCS codes provide additional specificity to describe the condition of and care afforded to a given patient. This article takes a closer look at these code updates as well as guidelines for reporting codes under new payment models.
Coding for damage control surgery and acute blood loss anemia can be difficult when clear provider documentation is not found within the medical record. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, outlines best practices for identifying anemia and ensuring more accurate documentation.
The first week of December was National Influenza Vaccination Week, a week highlighting the importance of continuing flu vaccination, particularly through the holiday season. Peggy Blue, MPH, CCS, CCS-P, CPC, CEMC , writes about CPT coding for vaccinations and immunization administration.
Updates to the 2018 CPT Manual , set to go into effect January 1, include several additions, revisions, and deletions to E/M and anesthesia procedural code sets. Familiarize yourself with these coding changes to aid in accurate reporting and prevent disruptions to the claims process. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
November, a month associated with the pleasure of eating, is also Stomach Cancer Awareness Month. In this article, Yvette M DeVay, MHA, CPC, CPMA, CIC, CPC-I, describes signs and symptoms of stomach cancer, and outlines best practices when assigning diagnostic and procedural codes for this disease.
Review vascular anatomy and terminology in order to aid in accurately assign codes for interventional radiology procedures such as angioplasties, atherectomies, and lower extremity revascularizations. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
