Allen Frady, RN-BSN, CCDS, CCS, CRC, explains the value of tracking and understanding key performance indicators (KPI), and gives advice on how facilities can improve on its practices.
Q: According to the ICD-10-CM Official Guidelines for Coding and Reporting, uncertain diagnoses should be documented at the time of discharge. If a consultant documents an uncertain diagnosis in the final or last progress note and not in the discharge summary, can we code that uncertain diagnosis?
According to the American Cancer Society, in 2017 there were an estimated 1,688,780 new cancer cases diagnosed and 600,920 cancer deaths in the U.S. In this article, Peggy Blue, MPH, CCS, CCS-P, CPC, CEMC , breaks down the usage of the ICD-10-CM neoplasm table and reviews coding for neoplasm admissions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Because Hierarchical Condition Categories (HCC) and similar risk-adjustment methodologies impact physician and hospital practices, James S. Kennedy, MD, CCS, CDIP, CCDS , reviews CMS’ Risk-Adjustment Data Validators (RADV) instructions to improve HCC compliance.
Emergency departments at designated trauma centers encounter some of the most complex patients—and with them, a complicated documentation web that’s difficult to untangle, making trauma case review essential for hospitals.
Hospitals reduced central line-associated bloodstream infections (CLABSI) by 50% between 2008 and 2016, according to a new report released by the Centers for Disease Control and Prevention (CDC).
James S. Kennedy, MD, CCS, CDIP, CCDS, reviews some ICD fundamentals and to help facilities develop a strategy that will ease the transition to the new administrative language as the federal government moves toward deployment of the International Classification of Diseases, 11th Edition, for Mortality and Morbidity Statistics (ICD-11-MMS).
Creating a query and knowing when to query can be complicated, and there are a number of training tactics that can prove successful for coders when trying to improve upon physician query practices. For this article, let’s take a look at when coders should query and when it’s appropriate for them to cite clinical evidence. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, writes that since there is such a prevalence for obesity in our nation, it’s a no brainer that correctly assigning and fully understanding the ICD-10-CM/PCS codes for obesity-related conditions is imperative for coders in any facility.
Q: We keep receiving denials for our use of ICD-10-CM code G94 (other disorders of brain in diseases classified elsewhere). Is there any coding guidance out there that can help our coding team decipher when we can use this code?
Only 12% of eligible hospitals signed up for CMS’ Bundled Payments for Care Improvement Model 2 initiative and 47% of them dropped out completely within two years, according to a recent study by the Journal of the American Medical Association .
With yearly ICD-10 code and guideline updates to the respiratory system, it’s important for coders to stay abreast of changes to ensure documentation and coding integrity. This article takes a closer look at the ICD-10-CM code updates as well as recent Coding Clinic guidance on the respiratory system. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Surprisingly, thyroid disease is more common than diabetes or heart disease, with an estimated 20 million Americans having some form of the disease. In this article, Yvette M. DeVay, MHA, CPC, CPMA, CIC, CPC-I gives readers a background on thyroid cancer and reviews ICD-10-CM/PCS coding for the disease.
On January 9, CMS announced the launch of Bundled Payments for Care Improvement Advanced from the agency’s Center for Medicare and Medicaid Innovation.
Q: If the attending physician documented, “likely mixed cardiogenic and septic shock,” can I assign ICD-10-CM codes R57.0 (cardiogenic shock) and R65.21 (severe sepsis with septic shock)?
Lynelle A. Clausen, RN, BSN, writes about the struggles she faces as a CDI specialist when dealing with vague documentation, lack of criteria, and the reporting of malnutrition.
While a facility’s case–mix index is an important metric to measure, program managers and directors warn that metrics mean different things to different stakeholders and that CDI programs need to work diligently to present their data within the context of a host of other important measures.
Victoria M. Hernandez, RHIA, CDIP, CCS, CCS-P , AHIMA-approved ICD-10-CM/PCS trainer, and Debi Primeau, RHIA, FAHIMA , highlight several areas that illustrate the increasing importance of code specificity to ensure accurate reporting and appropriate reimbursement.
Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, writes about the Office of the Inspector General’s (OIG) recent audit findings regarding the ICD-9-CM diagnosis code for kwashiorkor, and discusses what coders can do to stay compliant when coding guidance is lacking. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: I have a question regarding unilateral weakness from a previous stroke. The patient has ongoing weakness in both right arm and leg post cerebrovascular accident (CVA) and associated ataxia post CVA in 2013. What is the accurate code assignment?
