Providers are still working to understand the impact of the February release of the controversial third international consensus definitions for sepsis and septic shock. James S. Kennedy, MD, CCS, CDIP , tackles this new sepsis definition in part two of his two-part series.
With all the hoopla over sepsis, pressure ulcers, and diabetes coding, there’s a little gem of coding advice that has been overlooked since ICD-10 was released: pneumonia and chronic obstructive pulmonary disease. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , writes about these changes and helps to decipher the new guideline changes. Note: To access this free article, make sure you first register for the free content if you do not have a paid subscription.
Q: What is the correct procedure code for an esophagogastroduodenoscopy? Our coder coded 0DQ68ZZ (Repair, stomach, via natural or artificial opening, endoscopic), which groups to DRG 326, the same as an esophagectomy. The relative weight is 5.45. This does not seem right. Could you please clarify?
This October celebrates the eight month anniversary of the February release of the controversial third international consensus definitions for sepsis and septic shock. James S. Kennedy, MD, CCS, CDIP , tackles this new sepsis definition in part one of his two-part series.
Trey La Charité, MD , writes about how he feels the days of merely maintaining compliance with published coding guidelines are gone, and suggests ways to protect a facility and appeal audits.
In early August, hospitals got a last-minute reprieve from the Medicare Outpatient Observation Notice (MOON) notification requirement. CMS detailed the need for additional time to revise the standardized notification form that hospitals will need to use to notify patients about the financial implications of being assigned to observation services; and, as of now, the requirement is still in delay.
Q: I am never sure of correct sequencing when the admission is for flu, pneumonia, and asthma. The patient presented in the emergency department (ED) with shortness of breath, still tight after nebulizer treatment in the emergency room. The patient was kept for observation for one day, then was admitted. Documentation includes: Fever 101.8 in ED; respiratory rate (RR) 24; white blood cell count (WBC) 12.6 Influenza and upper respiratory tract infection Mild persistent asthma in exacerbation due to the above (wheezing, tachycardia in the ED, 130s); acute hypoxic respiratory failure (PO 90%). Superimposed RLL community-acquired pneumonia (CAP), per chest x-ray Can you suggest proper sequencing and if queries are needed?
Shannon Newell, RHIA, CCS, writes about how certain hospitals will be required to participate in the Comprehensive Joint Replacement Model and a new orthopedic payment model called SHFFT if an August 2 proposed rule is finalized.
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 definition, including the root operations that put in, put back, or move some or all of a body part.
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, discusses the new documentation requirements for pressure ulcer coding in the 2017 Official Guidelines for Coding and Reporting. Note: To access this free article, make sure you first register for the free content if you do not have a paid subscription.
Laura Legg, RHIT, CCS, CDIP , explains how the coming months will prove to be challenging for coders because of the new ICD-10 codes for both diagnoses and procedures beginning October 1. Along with that, we’ll see the end of the CMS grace period on code specificity for Part B physician payments and updated ICD-10-CM Official Coding Guidelines .
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, including Restriction and Occlusion. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Laurie L. Prescott, MSN, RN, CCDS, CDIP , writes that as many CDI teams work to expand their risk adjustment programs, a melding of two skill sets, that of CDI specialists and coding professionals, are required to succeed.
After an almost five-month deferment, the Beneficiary and Family Centered Care Quality Improvement Organizations resumed initial patient status reviews of short stays in acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities, CMS announced on their website.
Q: I am with a CDI program that is starting to explore severity of illness/risk of mortality (SOI/ROM). I personally have been reviewing for SOI/ROM for quite a while. I usually designate the impact (MCC/CC/SOI/ROM) after the billing is done and see if what I queried for made a final impact, and only take credit for those that do. I was told that regardless of the actual final impact on SOI/ROM, we should be taking credit for any SOI/ROM clarification as SOI/ROM impact. Which is the most accurate, “correct” way to capture the CDI impact for these types of clarifications?
Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer, writes that the majority of the 2017 IPPS final rule updates are consistent with those outlined in the proposed rule, but contain a few refinements. She reviews refinements to the number of claims-based outcomes linked to payment.
Sharme Brodie, RN, CCDS , discusses how to decipher between some potentially confusing—and possibly conflicting—information regarding diabetes documentation requirements.
CMS released a national coverage determination recently covering a percutaneous left atrial appendage closure through their “coverage with evidence development” policy. CMS says this policy will be fully implemented on October 3, 2016.
Q: The coders at my facility have started automatically linking congestive heart failure, hypertension, and chronic kidney disease (CKD) to the combination code without any documentation of CHF “due to” hypertension. There is no documentation of hypertensive heart disease anywhere in the record, and the diagnoses are not linked anywhere in the record.
