Q: Is there guidance on reviewing a record, such as an operative note, that has not been signed by a physician? I am at a facility that allows coding from unsigned transcriptions. I was always told that the information needs to be confirmed by a signature as valid before including that information in the review worksheet. Do you have any recommendations for this?
Q: I am having trouble with ICD-10-PCS coding for a perineal laceration repair. Some sources state that the correct code uses the perineal anatomic region, not muscle repair. Could you please clarify the correct ICD-10-PCS code for a second-degree obstetrical (perineum) laceration that includes muscle?
A 12-year-old male developed umbilical discomfort Monday and didn't eat much dinner. On Tuesday, he started vomiting at school and the pain shifted to his right lower quadrant. His parents brought him to the ED, where his vital signs showed:
Each new CMS fiscal year, MS-DRG weight and classification changes in the CMS IPPS final rule are closely scrutinized by coders and CDI specialists to identify any potential impact on documentation capture and code assignment processes.
Q: How can our team prepare for potential productivity losses post-ICD-10 implementation, specifically regarding procedure codes? Should we consider hiring additional staff or staff with a surgical background?
Q: In my facility, we are supposed to send an email to our physician advisor (PA) and to administration if a query is not answered within a week. However, this policy doesn’t work well because administration does not do anything with that information, and the PA doesn’t have time to review unanswered queries. Do you have any suggestions concerning when to let a query go unanswered?
The 2016 IPPS final rule continues CMS’ plan to shift Medicare payments from volume to quality. Shannon Newell, RHIA, CCS, and James S. Kennedy, MD, CCS, CDIP, analyze the rule and the impact it could have on providers.
ICD-10 implementation will arrive very soon, and many facilities are putting the final touches on their preparations. In the rush to complete coding education, documentation improvement, and system updates, HIM managers may not have looked at looming MS-DRG shifts.
Q: If the physician documents “concerning for,” “considering,” “cannot be ruled out,” or “cannot be excluded” for a diagnosis, is that considered an uncertain diagnosis? Can those terms be coded if the patient is being worked up? Are the terms “concerning for” and “considering” equal to the uncertain diagnosis terms “yet to be ruled out”?
Although CMS did not propose any changes to the 2-midnight rule in the fiscal year 2016 IPPS proposed rule, it signaled its intention to address short stays in the calendar year (CY) 2016 OPPS proposed rule. CMS followed through by introducing several proposed changes to the 2-midnight rule.
Acute kidney injury (AKI) is an abrupt decrease in kidney function that is reversible within three months of loss of function. Garry L. Huff, MD, CCS, CCDS, and Kim Yelton, RHIA, CCS, CDIP, review the clinical definition of AKI and coding for both ICD-9-CM and ICD-10-CM.
Q: I have been asked to build a query for a diagnosis of SIRS and/or sepsis for the following scenario: The patient was admitted for an infection urinary tract infection (UTI), pyelonephritis (PNA) and meets two SIRS criteria. The patient may be treated with oral or intravenous antibiotics, and may be on a general medical floor (not intensive care). The physician did not document SIRS or sepsis. I am having a hard time with this query because I am not sure if this would be considered adding new information to the chart or leading the physician by introducing a new diagnosis. Do you have any suggestions?
Coders and CDI specialists often rely on the encoder to determine the MS-DRG. Cheryl Ericson, MS, RN, CCDS, CDIP, reviews the steps necessary to determine the MS-DRG on your own.
Q: Can “in the setting of”' be interpreted as “due to” in ICD-10-CM? For example, the physician documented that the patient has a urinary tract infection in the setting of a urinary catheter.
ICD-10-PCS root operations Drainage, Extirpation, and Fragmentation involve removing material from the body, but in different ways. A nita Rapier, RHIT, CCS, Kristi Stanton, RHIT, CCS, CPC, and James Fee, MD, CCS, CCDS, offer tips for distinguishing between the root operations.
