The AHA's Coding Clinic for ICD-10-CM/PCS , Third Quarter 2015, opens with a discussion of the differences between excisional and non-excisional debridement-diagnoses with a long history of coding and clinical documentation confusion, explains Sharme Brodie, RN, CCDS.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , and AHIMA-approved ICD-10-CM/PCS trainer, writes that reporting imaging, nuclear medicine, and radiation therapy procedures will dramatically change depending upon whether the patient has been admitted into a hospital or is being cared for as an outpatient
A recent Association of Clinical Documentation Improvement Specialists poll says that 53% of respondents are not experiencing any real problems with ICD-10-CM/PCS, but coding experts have identified a few tricky diagnoses for coders to be aware of.
Cyndi Pickney, DO, FACP explains that as ICD-10 implementation approached last year, organizations reported varying levels of readiness and understanding of the impact on physician workflow, and now, there are unforeseen consequences.
For years, coding professionals have been tasked with ensuring that bills for Medicare patients include the proper elements of the diagnosis-related group (DRG) in order to try to accurately show a patient’s severity, but, as Robert S. Gold, MD , writes, there is much more to coding than DRG maximization.
Allen Frady, RN, BSN, CCS, CCDS , and Gwen S. Regenwether, BSN, RN , combat coders’ and clinical documentation improvement (CDI) specialists’ querying bad habits, and show how to support productivity and revenue flow for the facility.
CMS administers the Medicare program and it is currently the single largest payer for healthcare in the United States. Medicare Part A, B, C, and D, all encompass a wide variety of services, all of which providers need to understand to determine which services are covered for patients.
Root operations are the fundamental building block of ICD-10-PCS codes, but providers may not use the same terminology coders are familiar with. Review these root operations that involve taking out all or some of a body part.
Beginning April 1, approximately 800 hospitals will be required to participate in CMS’ new joint replacement payment model. Shannon Newell, RHIA, CCS, outlines the requirements and what providers need to do in order to prepare.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, reviews anatomic details related to hernias and how to use operative report details to report the appropriate procedure codes for hernia surgeries.
Laurie L. Prescott, RN, MSN, CCDS, CDIP, looks at the definitions for primary, principal, and secondary diagnoses and how to determine them from provider documentation.
Denials are on the rise for certain diagnoses, procedures, and regulations. Sarah C. Mendiola, Esq., LPN, CPC, outlines steps providers can take to reduce denials by focusing on certain documentation details.
Even before ICD-10, unclear definitions for certain diagnoses and procedures led to confusion for coders trying to interpret physician documentation. Robert S. Gold, MD, writes about conditions in the new code set that could lead to potential risks for providers.
Gwen S. Regenwether, BSN, RN, and Cheree A. Lueck, BSN, RN, look at how to use audit and query rate information to improve documentation at a facility and how to encourage continuing education and collaboration going forward.
Joel Moorhead, MD, PhD, CPC, writes about details for spinal conditions for coders to consider when choosing the most accurate ICD-10 codes for diagnoses and procedures.
Gwen S. Regenwether, BSN, RN, and Cheree A. Lueck, BSN, RN, discuss how the clinical documentation improvement department at their facility operates and their process for conducting a baseline audit and determining query rates across specialties.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, reviews updates in Coding Clinic about coding orthopedic procedures in ICD-10-PCS, coma data in ICD-10-CM, and both cardiovascular procedures and diagnoses.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about how to report biopsies in ICD-10-PCS since the code set does not include the term among available root operations.
Marianne Durling, MHA, RHIA, CDIP, CCS, CPC, CIC, an HIM director for a health system in North Carolina, provides her wish list for her department and coders, including thoughts on implementing a CDI program, working with payers, and hiring staff.
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP, writes about the importance of tracking venous thromboembolism at hospitals and how to ensure physician documentation includes the correct level of detail to capture it.
