Spinal fusion is a procedure to join, or fuse, two or more vertebrae and can be performed in both the inpatient and outpatient settings. Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, MCP, review spinal anatomy before discussing correct ICD-9-CM Vol. 3 and ICD-10-PCS coding for inpatient spinal fusions.
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.
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: ICD-9-CM includes Pott’s fracture as an alternate term for a bimalleolar fracture. However, ICD-10-CM doesn’t include that term in either the Alphabetic Index or the Tabular List. If the physician documents a Pott’s fracture, can we automatically use the code for bimalleolar fractures in ICD-10-CM, even though the term is not in the index?
In ICD-10-CM, you need to communicate with the medical staff about the specific elements that are important for pathologic fractures, because the coding is different than it used to be and it's so different from traumatic fractures.
Q: We know that we can look at the radiology report to get some specifics about a fracture. When it comes to an open fracture in ICD-10-CM, can you determine the Gustilo-Anderson classification, whether it's I, II, IIIA, IIIB, or IIIC, based on a description of the wound? Or does the physician actually have to document, “It's a Gustilo type I" or "type III”?
CMS designates certain procedures as inpatient-only, meaning it will only reimburse the facility when the procedure is performed on an inpatient. However, CMS identifies these procedures using outpatient CPT ® codes. Beverly Cunningham, MS, RN, and Kimberly A.H. Baker, JD, CPC, discuss the process for identifying and coding inpatient-only procedures.
CMS' introduction of the 2-midnight rule in the 2014 IPPS final rule makes properly identifying inpatient-only procedures even more important for hospitals.
Physician documentation drives quality measures, but physicians often don't understand how the quality of their documenation relates to their quality of care.
Q: A few days into the patient’s stay, an order for a Foley catheter was placed for incontinence and around the same time the physician documented a urinary tract infection (UTI). Would it be appropriate to query the physician regarding the relationship of the UTI to the Foley? Our infection control department caught this but we did not. I am concerned about this for two reasons; first, I worry about writing a leading query and second, whether the UTI could be considered a hospital-acquired condition (HAC) if additional documentation isn’t provided.
Sequela, or late effect, is the remaining or lasting condition produced after the acute stage of a condition or injury has ended. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, reviews the correct way to code for sequelae in ICD-9-CM and ICD-10-CM.
The April 1 confirmation of the delay in implementing the ICD-10 code set until at least October 1, 2015, certainly took the wind out of many healthcare organizations' sails.
CMS' 2015 IPPS proposed rule, released April 30, focuses on quality measures, such as HAC reduction, readmissions reduction, and hospital value-based purchasing (VBP) programs.
Q: We had a question regarding documentation in a record of SIRS due to acute peritonitis without sepsis. Our critical care physician on that case called it severe sepsis as well. What would you do in a situation like that?
Q: I’m in a little debate: Does documentation of the patient’s body mass index (BMI) need to come from an ancillary clinician, like the dietitian or nurse? I thought that we could use such ancillary documentation for clinical indicators supporting our physician query, but the treating physician needed to document the BMI. Can you help clarify this for me?
CMS’ 2015 IPPS proposed rule , released April 30, focuses on quality measures, such as the hospital-acquired condition (HAC) reduction, readmissions reduction, and hospital value-based purchasing (VBP) programs.
CMS’ 2015 IPPS proposed rule , released April 30, focuses on quality measures, such as the hospital-acquired condition (HAC) reduction, readmissions reduction, and hospital value-based purchasing and hospital readmissions reduction programs.
A diabetic patient is admitted with gangrene. The physician does not specifically link the diabetes and the gangrene, but also does not document any other potential cause of the gangrene. Should you code both conditions?
Congress needed just a week to throw a huge monkey wrench into the healthcare industry's plans for ICD-10 implementation. On March 26, House leadership introduced H.R. 4302, "Protecting Access to Medicare Act of 2014." By April 1, the bill had passed the Senate and been signed into law by President Obama.
At the time of this publication, the Protecting Access to Medicare Act of 2014 bill was recently passed. The status quo regarding physician reimbursement from Medicare has been maintained. So what? That system has been broken for 20 years. ICD-10 will be postponed for provider billing for another year. So what? Life will go on as it has for the past 36 years with ICD-9-CM. In other words, nothing has changed. We're good for another year. Pressure's off! ...Right?
When Congress passed the Protecting Access to Medicare Act of 2014, it mandated at least a one-year delay in ICD-10 implementation. Members of the Briefings on Coding Compliance Strategies editorial board, who represent a wide range of industry stakeholders, offered their thoughts on two questions related to the delay.
CMS’ 2015 IPPS proposed rule , released April 30, focuses on quality measures, such as the hospital-acquired condition (HAC) reduction, readmissions reduction, and hospital value-based purchasing and hospital readmissions reduction programs.
Q: A patient is admitted with a high white blood count, tachycardia, tachypnea, and chills. The blood culture shows positive for methicillin-resistant Staphylococcus aureus (MRSA). The attending physician documents MRSA sepsis in the progress notes. Antibiotics are changed based on the blood culture and the patient is treated with appropriate antibiotics. Due to poor vascular access, a central venous catheter (CVC) is inserted and antibiotics are infused through this access. The patient responded slowly to treatment and CVC access becomes red and inflamed. The catheter is removed and cultured. The physician documents this to be an infection due to MRSA. What’s the diagnosis code for this?
Cheryl Ericson, MS, RN, CCDS, CDIP, discusses the difference between “after study” and “due to” when it comes to choosing the correct principal diagnosis .
Q: Our physicians document a diagnosis of pneumonia but do not normally make a specific connection with the patient's ventilator status, even when this is obvious from the record. For example, the patient's been on the ventilator support immediately prior to the diagnosis. Can I report this as ventilator-associated pneumonia in ICD-10-CM without the documentation specifically connecting the conditions?
ICD-10-CM includes more specificity than ICD-9-CM, but it still includes unspecified codes. Adele Towers, MD, MPH, Joanne Schade-Boyce, BSDH, MS, CPC, ACS, PCS, Michael Gallagher, MD, MBA, MPH, Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC , and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, explain when reporting an unspecified ICD-10-CM code is a good option.
Coding Clinic's Third and Fourth Quarter 2013 issues focus considerable attention on ICD-10-PCS procedure coding. On p. 18, Coding Clinic Third Quarter 2013 states that the coding of a peripherally inserted central catheter (PICC) depends on the end placement of the PICC line?that is, where the device ends up.
Coders and clinicians seem to speak different languages. CDI specialists often serve as the translators between clinicians and coders, so it's important that all three groups work together.
Heather Taillon, RHIA, Cheryl Collins, BS, RN , and Andrea Clark, RHIA, CCS, CPC-H , explain the basic rules regarding principal diagnosis selection in general and for neoplasms in particular in ICD-9-CM.
Coders may need to have a conversation with physicians about how changes in ICD-10-CM could require additional documentation for mental disorders due to a known physiological condition. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, compares coding for these conditions in ICD-9-CM and ICD-10-CM.
When it comes to coding malnutrition, coders need to see very specific information in the physician documentation. James S. Kennedy, MD, CCS, William E. Haik, MD, FCCP, CDIP , and Mindy Hamilton, RD, LD, review the clinical factors for malnutrition and how to assign the correct ICD-9-CM codes.
Whether you work in a dedicated children’s hospital or a general hospital with a pediatric service line, you will likely come into contact with coding charts of kids. Sometimes they are easy (e.g., an inguinal hernia repair without obstruction or gangrene is an inguinal hernia repair without obstruction or gangrene—except it has to be identified as right or left in ICD-10). Sometimes they are not so easy (e.g., complex congenital diseases and their manifestations and complications).
Inpatient coders will see an entirely new coding system October 1 when they begin officially using ICD-10-PCS. However, MS-DRGs are not changing. The only thing that is changing is what codes map to a particular MS-DRG.
The UHDDS defines principal diagnosis as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. That means the principal diagnosis is not always the condition that brought the patient into the hospital.
Codes for epilepsy and migraine headaches are getting a makeover for ICD-10-CM. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, reviews the additional specificity in the new ICD-10-CM codes.
Q: Does the physician have to document the stage of a decubitus ulcer or can it be a wound care nurse? Does that person have to document stage 1 or can he or she describe the wound?
Physicians can biopsy numerous body sites and structures, including muscles, organs, and fluids. Mark N. Dominesey, MBA, RN, CCDS, CDIP, and Nena Scott, MSEd, RHIA, CCS, CCS-P, dig into biopsy coding in both ICD-9-CM and ICD-10-CM.
Q: Can you explain when a neoplasm should be listed as the principal diagnosis? We have some coders who believe the neoplasm should always be the principal diagnosis.
