William E. Haik, MD, FCCP, CDIP , AHIMA-approved ICD-10-CM/PCS trainer, Jonathan Besler, CPA, MA , and Mary Devine, RN , write that while it is well-known that ICD-10-CM/PCS code assignment impacts hospital reimbursement and compliance, there is an additional code that often flies under the radar for inpatient coders and has a huge impact on reimbursement: the discharge status code.
Adriane Martin, DO, FACOS, CCDS, summarizes the proposed changes found in the fiscal year (FY) 2019 IPPS proposed rule, broken down by Major Diagnostic Category (MDC), that would impact ICD-10-CM/PCS codes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Amy Sanderson, MD, says that the term “dysphagia” has many synonyms used by providers in medical documentation. However, not all of these symptoms are able to describe the diagnosis with enough specificity so that it can be translated into its corresponding code assignment.
In many cases, knowing when to query is simple, but the more challenging cases contain clues that require additional interpretation. Drew Siegel, MD, CCDS, takes a look at a few of the more interesting and often undocumented diagnoses, including respiratory failure and acute kidney injury, and points out the diagnostic clues to form a compliant query.
Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS , writes that beyond auditing for code assignment, coding reviews also provide an opportunity for you to conduct a thorough compliance evaluation that not only addresses other components of the coding process but also the integrity of the patient’s record. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Erica E. Remer, MD, FACEP, CCDS, reviews recent Coding Clinic guidance surrounding the code assignment of a Salter-Harris type I physeal fracture of the third metatarsal bone of the left foot.
Just like their inpatient acute care counterparts, inpatient psychiatric facilities use ICD-10-CM codes, but their payment structure, documentation requirements, prevalent clinical conditions, and additional documentation requirements needing capture are vastly different.
James S. Kennedy, MD, CCS, CDIP, CCDS , writes that ICD-10-CM/PCS documentation and coding rules surrounding patient safety indicators (PSI) must be honored in order to ensure proper compliance and reimbursement.
According to the National Institute of Health, approximately 100,000 Americans have sickle-cell disease. In this article, Peggy Blue, MPH, CCS, CCS-P, CPC, CEMC , breaks down the complexities of the disease and clarifies reporting of the diagnosis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
A common question that coders often ask is when to report a secondary diagnosis. In part two of this two-part series, Gloryanne Bryant, RHIA, CDIP, CCS, CCDS , looks at the chapter-specific coding guidelines related to secondary diagnosis coding found in the ICD-10-CM Official Guidelines for Coding and Reporting.
Allen Frady, RN-BSN, CCDS, CCS, CRC, reviews proposed changes applicable to coding and CDI teams within the fiscal year (FY) 2019 IPPS proposed rule including HIV disease, ARDS, and CC/MCC changes.
Allen Frady, RN-BSN, CCDS, CCS, CRC, reviews various guidance related to clinical validation to help coders and CDI teams better navigate the complex topic.
Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRD, CCDS, writes that while the fiscal year (FY) 2019 IPPS proposed rule is considering the downgrade of ICD-10-CM code B20 (human immunodeficiency virus [HIV] disease) from an MCC to a CC, it does not mean that diagnosing and coding for HIV has lessened in complexity.
A common question that coders often ask is when to report a secondary diagnosis. In part one of this two-part series, Gloryanne Bryant, RHIA, CDIP, CCS, CCDS , looks at the general coding guidelines related to secondary diagnosis coding found in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting.
Allen Frady, RN-BSN, CCDS, CCS, CRC, writes about guidance related to documenting acute respiratory insufficiency and gives tips to coders and CDI teams on what to do when the conditions are over-documented postoperatively.
A diagnosis of autism spectrum disorder (ASD) now includes several conditions that used to be diagnosed separately: autistic disorder, pervasive developmental disorder not otherwise specified, and Asperger’s syndrome. Peggy Blue, MPH, CCS, CCS-P, CPC, CEMC , reviews these terms to aid accurate coding. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
James S. Kennedy, MD, CCS, CDIP, CCDS, writes that the various approaches hospital systems use to optimize their DRG-based case-mix index or HCC-based risk adjustment factor scores will likely conflict with how an accountability agent will see those measurements.
James S. Kennedy, MD, CCS, CCDS, CDIP, writes that clinical validity, documentation, and ICD-10-CM coding applicable to liver disease remains a great challenge to those invested in severity and risk-adjustment coding compliance. In this article, he reviews several pitfalls that could await facilities.
Danielle Richmond says that while inpatient coder shortages are nowhere near what they were with ICD-9-CM, new challenges have emerged. This article shares important advice for any managers trying to improve their coder recruitment and hiring process.
Coders often seek definitions for realistic productivity benchmarks, and standards depend on how a given facility establishes the responsibilities and expectations of its team. Therefore, before assessing a coder’s success, a facility must set goals that define that success. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
