Richard D. Pinson, MD, FACP, CCS , discusses the new Sepsis-3 definition and how the classification has been the subject of great controversy and consternation since its publication in The Journal of the American Medical Association.
Robert Stein, MD, CCDS, and Shannon Newell, RHIA, CCS, co-author this article that provides insights into how clinical documentation and reported codes may impact payments and offer guidance on some common CDI challenges to strengthening data quality. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP , writes about how computer-assisted coding software can be used to boost coding accuracy and productivity, in addition to being an important tool for the remote coder.
James Kennedy, MD, CCS, CDIP , offers his take on AHIMA’s recently published clinical validation practice brief. Given that AHIMA is one of the ICD-10 Cooperating Parties, their practice briefs must be read closely, and if agreeable, incorporated into one’s compliance plan. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Shannon Newell, RHIA, CCS, writes about recently proposed modifications to Patient Safety Indicator 90, and how a fact sheet released by the measure's owner, the Agency for Healthcare Research and Quality, provides insights into what changes may lie ahead.
"You are your own best teacher," or so the old adage goes. Sure, goodies and gifts are great for recognizing high-quality documentation, but for CDI teams struggling to obtain physician buy-in, the best strategy may be found in their providers' own records.
The accurate capture of acute respiratory failure has been a long-standing challenge for CDI programs. The accurate reporting of this condition as a post-procedural event can be even more difficult.
We as coders, clinical documentation specialists, and compliance officers, are actively invested in coding compliance, aren't we? AHIMA and ACDIS emphasize coding compliance in their codes of ethics. If we aren't interested in coding compliance, why are we reading newsletters named Briefings in Coding Compliance Strategies and other similar publications?
Since the physician doesn't need to use a specific root operation term in documentation, coders should not rely solely on the term the physician uses. Coders need to know the definitions and the nuances of the root operations, especially those involving a device.
Laurie L. Prescott, MSN, RN, CCDS, CDIP, provides coders with tips on coding heart failure, obstetrics, and linking language, and also offers the latest guidance given by AHA Coding Clinic for ICD-10-CM/PCS ® on these topics.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, address the inpatient side of bariatric surgery, and how obesity and body mass index play a role in coding.
Paul Evans, RHIA, CCS, CCS-P, CCDS, give coders ICD-10-PCS documentation and coding tips for three of the most common, and commonly misunderstood, procedures performed via bronchoscopy.
Since the physician doesn't need to document a specific root operation, coders cannot rely solely on the terms the physician uses; thus it is important for each coder to fully understand each root operation, especially Control and Repair. Note: To access this free article, make sure you first register if you do not have a paid subscription.
When compared to data from past surveys, HCPro's 2016 HIM director and manager salary survey revealed a harsh truth that many HIM professionals already know: There has been little movement in HIM manager and director salaries over the years.
Following are some ICD-10-PCS documentation and coding tips for three of the most common (and commonly misunderstood/miscoded) procedures performed via bronchoscopy.
If you've ever read an issue of HCPro's flagship newsletter HIM Briefings, if you've ever picked up an issue of Briefings on Coding Compliance Strategies and turned to the column "Clinically Speaking," if you've been a regular listener of HCPro's HIM or CDI audio conferences or webinars, if you're a member of the Association of Clinical Documentation Improvement Specialists (ACDIS) and subscribe to the "CDI Talk" newsgroup or listen to the ACDIS quarterly conference calls, chances are you've encountered the phenomenon known as Robert Gold, MD.
The fiscal year (FY) 2017 IPPS proposed rule alerted us to some significant changes to Patient Safety Indicator (PSI) 90, one of which is a new name: the Patient Safety and Adverse Events Composite. A fact sheet released by the measure's owner, the Agency for Healthcare Research and Quality (AHRQ), provides insights into what may lie ahead if the proposed rule's content is finalized.
The last few weeks have brought us some direction, though, including the release of approximately 1,900 new ICD-10-CM codes for 2017. (The list can be found on CMS' website.) We also have a list of approximately 3,600 new ICD-10-PCS codes for 2017. (This is also available on CMS' site.) Of course, we will also be looking for changes in DRG mappings and the CC/MCC lists, which will likely appear later this summer.
Allow me to introduce myself as the new columnist for the "Clinically Speaking" section of Briefings on Coding Compliance Strategies after the recent passing of Dr. Bob Gold. My hope is that this column will continue his legacy of helping you promote complete, precise, and clinically congruent ICD-10-CM/PCS code assignments resulting in defendable DRG assignment and applicable severity and risk adjustment. Thank you for this privilege of writing to you; I solicit your feedback and advice.
Michelle M. Wieczorek, RN, RHIT, CPHQ, discusses how documentation and coding can impact your facility’s data reported for hospital-acquired conditions and present on admission indicators.
Shannon Newell, RHIA, CCS , AHIMA-approved ICD-10-CM/PCS trainer, writes about significant changes to PSI 90 in the 2017 IPPS proposed rule, one of which is a new name–The Patient Safety and Adverse Events Composite.
Kimberly Cunningham, CPC, CIC, CCS , and other professionals comment on commonly seen MS-DRGs and inpatient conditions, including which terms coders need to look for in documentation to arrive at the most accurate MS-DRG and codes. Note: To access this free article, make sure you first register if you do not have a paid subscription.
The FY 2017 IPPS proposed rule addresses MS-DRG classifications and relative weights pertaining to categories such as Excision of ileum, Bypass procedures of the veins, Removal and Replacement of knee joints, and pacemaker procedure code combinations.
Katy Good, RN, BSN, CCDS, CCS, Paul Evans, RHIA, CCS, CCS-P, CCDS, Laurie Prescott, MSN, RN, CCDS, and Gloryanne Bryant, BS, RHIA, CDIP, CCS, CCDS, all comment on how over-querying is a common concern in clinical document improvement, and how over-querying can cause delays in documentation and coding processes.
Shannon Newell, RHIA, CCS , AHIMA-approved ICD-10-CM/PCS trainer discusses modifications and expansions to claims-based quality and cost outcome measures in the 2017 IPPS proposed rule. Note: To access this free article, make sure you first register if you do not have a paid subscription.
On April 18, CMS issued its anticipated IPPS proposed rule for FY 2017. This year's proposed rule is very dense, including multiple coding fixes and updates, changes to payment provisions, quality updates, and even something for utilization review.
The FY 2017 IPPS proposed rule released April 27 is replete with modifications and expansions to claims-based quality and cost outcome measures. Although many of these proposed changes are for future fiscal years, ICD-10 codes reported for current discharges will impact the future financial performance for our organizations.
The FY 2017 IPPS proposed rule includes updates to payment rates and quality initiatives, but some of the most extensive changes pertain to proposals for certain MS-DRG classifications and relative weights.
Kimberly Anderwood Hoy Baker, JD, writes about the many changes in the 2017 IPPS proposed rule, and explains how almost everyone could be affected by CMS’ proposals.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, reviews scenarios for initial, subsequent, and sequela encounters, and helps coders better understand how to assign seventh characters for each type of encounter. Note: To access this free article, make sure you first register if you do not have a paid subscription.
The FY 2017 IPPS proposed rule addresses MS-DRG classifications and relative weights pertaining to the categories of other cardiothoracic procedures without MCC, and injuries, poisonings and toxic effects of drugs.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, discusses strategies for reporting, and better understanding, pyeloplasty in ICD-10-PCS. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Robert S. Gold, MD, writes about important changes made in hypertension since ICD-9-CM, and helps coders better understand the relatively complex diagnosis.
With a widespread lack of awareness of national best practice guidelines for malnutrition, Joannie Crotts, RN, BSN, CPC , and Szilvia Kovacs, MS, RD, LDN , explain how identifying and diagnosing the condition is often still difficult, and how important changes can be made to improve a facility’s malnutrition program.
ICD-10-PCS defines the root operations in very specific ways and coders need to know the definitions and the nuances of the root operations. Learn more about root operations that involve the physician looking at a patient, Inspection and Map.
Anny Pang Yuen, RHIA, CCS, CCDS, CDIP and Laurie Prescott, MSN, RN, CCDS, CDIP discuss how for the past few years, healthcare professionals have focused on ICD-10 preparation, and while prep work paid off and the transition has been largely successful, facilities are experiencing a few bumps as their focus shifts from preparation to improvement of clinical documentation and coding.
Robert S. Gold, MD, writes about the significant changes in documentation needs for diseases of the brain and how this can affect patient data, as well as the treatment needs of the patients both during a hospital stay and afterward.
When the Quality Improvement Organizations (QIO) took over the role of education and enforcement for the 2-midnight rule on October 1, 2015, many anticipated that their reviews would only look at records from that date forward, but some hospitals have reported QIO record requests zeroing in on cases as far back as May 2015 and requesting charts for inpatient-only surgeries.
Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer, explains how under the Comprehensive Care for Joint Replacement, acute care hospitals in selected geographic areas assume quality and payment accountability for retrospectively calculated bundled payments for lower extremity joint replacement episodes, and how this now requires a CDI evolution.
Richard D. Pinson, MD, FACP, CCS , describes the Third International Consensus Definitions for sepsis and septic shock as published on February 23 in the Journal of the American Medical Association , and what the impact will be for both clinicians and coders.
There have been some significant changes in documentation needs for diseases of the brain since October 2015. These can affect accurate patient data as well as providing information for the treatment needs of the patients both during a hospital stay and afterwards. They will enable patient information to be available to all providers and ensure that you get paid appropriately for the complexity of the patients under your care.
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)¹ as published on February 23 in the Journal of the American Medical Association represents a radical departure from the prior sepsis definitions in 1991² (identified as Sepsis-1) and 2001³ (identified as Sepsis-2) and subsequent Surviving Sepsis Campaign (SSC) guidelines through 2015.
Under the CJR, which began April 1, acute care hospitals in selected geographic areas assume quality and payment accountability for retrospectively calculated bundled payments for lower extremity joint replacement (LEJR) episodes. Episodes begin with admission to an acute care hospital for an LEJR procedure that is paid under the IPPS through MS-DRGs 469 or 470 (Major joint replacement or reattachment of lower extremity with or without MCC, respectively) and end 90 days after the date of discharge from the hospital.
Barbara A. Anderson, RN, MSM, says that in 2014, 66% of 318 hospitals surveyed by AHIMA had a CDI program in place. Anderson explains how CDI programs can be a valuable bridge between clinical care and coding at hospitals, and gives examples on how to improve upon a facility’s program.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, writes about key details in documentation that coders will need to look for in order to report procedures using the root operation Dilation.
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.
