ICD-10-CM is similar to ICD-9-CM, but coders need to watch out for differences which could lead to incorrect coding. Nelly Leon-Chisen, RHIA, Gretchen Young-Charles, RHIA, and Sarah A. Serling, CPC, CPC-H, CPC-I, CEMC, CCS-P, CCS , discuss possible pitfalls for coding myocardial infarctions, neoplasms, and external causes in ICD-10-CM.
Many physicians remain reluctant to admit when a complication occurs as the direct result of the medical care they provide. Trey La Charité, MD , reviews hypothetical situations to help illustrate how coders and clinical documentation improvement specialists can handle complications.
ICD-10-PCS codes consist of seven characters, each of which identifies a unique, specific piece of information. For most of the codes in the Medical and Surgical section, each character represents the same information every time.
Physicians use a lot of shortcuts and abbreviations. Some of them may even make it to the official abbreviation list at a hospital. Some don't. Even if they do, some physicians will use the wrong term.
Malnutrition is at its most basic level any nutritional imbalance. While it can be overnutrition, such as being overweight, obese, or morbidly obese, providers more commonly equate malnutrition with undernutrition, which is a continuum of inadequate intake, impaired absorption, altered transport, and altered nutrient utilization.
Q: How specific does the physician have to be for the location of the acute myocardial infarction (MI) in ICD-10-CM? We don’t do catheterizations at my facility .
When a physician closes off varices, coders must determine the location and method the physician used to correctly build an ICD-10-PCS code. Nena Scott, MSEd, RHIA, CCS, CCS-P, and Gretchen Young-Charles, RHIA, review the components of different procedures for closing off varices and how to code those procedures in ICD-10-PCS.
Clinical auditors are often not able to translate from ICD-9 to CPT ® to determine a procedure is inpatient-only, which leads to denials. Kimberly A.H. Baker, JD, CPC, and Beverly Cunningham, MS, RN, reveal common causes of denials and what hospitals can do to overturn incorrect denials.
Q: My colleagues and I continually wrestle with this question: Must all diagnoses on an inpatient chart be listed in the discharge summary for them to be coded?
CMS designates a certain set of procedures as inpatient-only, meaning it will only reimburse facilities for these procedures when they are performed in the inpatient setting. Inpatient-only procedures present numerous problems for hospitals.
If coders choose the wrong root operation in ICD-10-PCS, they will arrive at an incorrect code. Nena Scott, MSEd, RHIA, CCS, CCS-P, AHIMA-approved ICD-10-CM/PCS trainer, Gretchen Young-Charles, RHIA, Anita Rapier, RHIT, CCS, and Nelly Leon-Chisen, RHIA, discuss some of the root operation clarifications offered by Coding Clinic .
Not feeling well? The problem could be in your small intestine. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, reviews common conditions related to the small intestine.
Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests, but they all come back normal. In the discharge note, the physician documents “abdominal pain, gastroenteritis versus irritable bowel syndrome (IBS).” When I first started as a CDI specialist I was told we could not use diagnoses when "versus” was stated, and that we had to query for clarification.
The 2015 IPPS final rule focused on quality measures. James S. Kennedy, MD, CCS, CDIP, and Cheryl Ericson, MS, RN, CCDS, CDI-P, highlight the changes and explain the role of coding in quality scores.
ICD-10-PCS root operations Control and Repair are used when a procedure doesn’t really fit into a different root operation. Nena Scott, MSEd, RHIA, CCS, CCS-P, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS , discuss when coders should use these two root operations.
Q: We’re having a lot of discussions with physicians right now and need to get some clarity on acute cor pulmonale versus chronic. Do you have any insight on that differentiation between the two with right-sided heart failure, chronic obstructive pulmonary disease (COPD), shortness of breath, and edema?
Quality measures, such as the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program, form the basis of the 2015 IPPS final rule, released August 4.
CMS proposed a major change to physician certification requirements in the 2015 OPPS proposed rule. Kimberly A.H. Baker, JD and James S. Kennedy, MD, CCS, CDIP, break down how the change could affect inpatient admissions.
Q: How would the following be viewed if it was included in a cardiology consult note: Mr. Jones has paroxysmal atrial fibrillation. He had a recurrence last night which was asymptomatic. We think this happens all the time at home. This is not a pacing post-conditioning (PPC). He is back in normal sinus rhythm (NSR). I would restart his warfarin if Dr. Smith will allow. Goal International Normalized Ratio (INR) is 2-3.
