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.
Emergency departments (ED) at designated trauma centers encounter some of the most complex patients—and with them, a complicated documentation web that’s difficult for even the most experienced CDI specialists and coders to untangle.
Greek philosopher Heraclitus once said the only constant is change. With the release of the fiscal year (FY) 2019 IPPS proposed rule , and all of the changes it contains, CMS has certainly proven Heraclitus correct. The rule applies to 3,257 acute care hospitals, and once finalized, will affect discharges on or after October 1.
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.
In inpatient coding, all diagnoses that affect the current hospital stay must be reported. In addition, the Uniform Hospital Discharge Data Set is commonly followed for reporting secondary diagnoses; it says that other (or additional) diagnoses are defined as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay."
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.
Nearly one-third of the world’s population is overweight or obese, including an estimated 160 million Americans, according to the Institute for Health Metrics and Evaluation . These statistics are alarming, especially considering that obesity is linked to many other conditions such as heart disease, stroke, Type 2 diabetes, and certain types of cancer.
Inpatient coding audits are performed for different purposes by individuals within and outside of the hospital. Coding audits can be categorized in various ways as shown below, but these attributes are not exclusive: Audits will have several characteristics at a time.