Physicians often use the terms acute renal failure (ARF) and acute kidney injury (AKI) interchangeably to describe an abrupt decrease in kidney function that is reversible within three months of loss of function.
With fewer than 100 days until ICD-10-CM/PCS implementation, plenty of questions still remain about ICD-10-PCS coding. The AHA's Coding Clinic for ICD-10 continues to provide updates and guidance for a variety of inpatient procedures, both routine and not so routine. We examine some of that guidance in this article.
Respiratory failure, whether acute or chronic and whether following surgery or not, is one diagnosis that is always an easy target for those who abuse the documentation and assignment of ICD codes.
PSI 12 evaluates the hospital's risk-adjusted rate of perioperative deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in surgical discharges for patients 18 years and older. Performance for PSI 12 contributes 25.8% of the PSI 90 composite score under the Hospital-Acquired Condition Reduction Program.
Q: In ICD-9-CM, sprains and strains fall under the same codes. Will that also be the case in ICD-10-CM or are we going to report these injuries separately?
Coding Clinic serves as the Supreme Court in interpreting ICD?9?CM or ICD?10?CM/PCS and their guidelines. James S. Kennedy, MD, CCS, CDIP, Kyra Brown, RHIA, CCS, and Nelly Leon-Chisen, RHIA, discuss the best ways to use this additional guidance.
CMS provided plenty of proposed refinements to quality measures in the 2016 IPPS proposed rule, but did not suggest any changes to the 2-midnight rule. Kimberly A.H. Baker, JD, CPC, James S. Kennedy, MD, CCS, CDIP, and Shannon Newell, RHIA, CCS, highlight the most significant proposed changes.
Shannon Newell, RHIA, CCS, Steve Weichhand, and Sean Johnson conclude their four-part series on PSI 90 with an in-depth look at PSI 12, which evaluates a hospital’s risk adjusted rate of perioperative deep vein thrombosis and/or pulmonary embolism in surgical discharges for patients 18 years and older.
Q: When I started as a coder, I learned that the complication code, such as from ICD-9-CM series 998 or 999, takes precedence as the reason of admission when present with another contributing condition. Is this correct, and is there any written guidance from AHA Coding Clinic for ICD-9-CM/ICD-10-CM/PCS that discusses this?
ICD-10-CM will still allow coders to report unspecified codes. However, coders will not have that option in ICD-10-PCS. Every character has to have a value, which will lead to an increase in surgical queries.
In the third part of our series on Patient Safety Indicator 90, we focus on inclusions, exclusions, and coding and documentation vulnerabilities for PSI 7.
The 2016 OPPS proposed rule is likely to continue CMS' trend of expanded packaging and feature refinements and expansion of comprehensive APCs based on comments CMS has made in prior rules.
Coders tell a patient’s story with a principal diagnosis and additional diagnoses, some of which are CCs or MCCs. William E. Haik, MD, FCCP, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, James Fee, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, and Cheryl Ericson, MS, RN, CCDS, CDIP, explain the value of educating physicians and coders about CCs and MCCs.
Q: Should “diabetes with gastroparesis” be coded as 536.3, diabetes with a complication code? I understood that the term ‘"with’" can link two diagnoses, but that it does not represent a cause-and-effect relationship. Can you please clarify this, and why a cause-and-effect relationship can be assumed in the term “diabetes with gastroparesis”?
Patient Safety Indicator 15 tracks events during surgical procedures that can hurt patients, but not whether the patient actually suffers harm from the event. Robert S. Gold, MD, identifies some of the challenges involved with this quality measure.
Coders and clinical documentation improvement specialists need to pay attention to what conditions are considered CCs and MCCs, as well as sequencing rules which could affect MS-DRGs. Laurie L. Prescott, MSN, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, and William E. Haik, MD, FCCP, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, discuss some common CCs and MCCs.
