The only difference between ICD-10-PCS root operations Excision and Resection is the amount of the body part removed. Jennifer Avery, CCS, COC, CPC, CPC-I, Anita Rapier, RHIT, CCS, and Cheree Lueck, BSN, RN, provide tips for determining the correct root operation.
In ICD-10-CM, to tell the patient’s whole story, coders need to report external cause codes. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, explains the benefits of these codes and how to report them.
ICD-10-PCS will completely change the way coders report inpatient procedures. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA, reveal potential trouble spots for the new coding system.
Q: If the physician documents “concerning for,” “considering,” “cannot be ruled out,” or “cannot be excluded” for a diagnosis, is that considered an uncertain diagnosis? Can those terms be coded if the patient is being worked up? Are the terms “concerning for” and “considering” equal to the uncertain diagnosis terms “yet to be ruled out”?
With Recovery Auditor audits on hold, hospitals may have experienced a decrease in the number of audits that must be addressed. Cathie Wilde, RHIA, CCS, and Kim Carr, RHIT, CCS, CDIP, CCDS, explain why organizations still need to be able to justify code assignment.
Medical record audits provide opportunities to educate coders, physicians, and/or clinical documentation improvement specialists. Robert S. Gold, MD, offers tidbits about volume overload and heart failure from recent reviews he’s done.
Drainage procedures can be therapeutic in nature or diagnostic, such as when a physician removes a fluid or gas for biopsy. A nita Rapier, RHIT, CCS, Nelly Leon-Chisen, RHIA, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS , highlight the differences in coding diagnostic and therapeutic thoracocentesis and lumbar tap procedures in ICD-10-PCS.
Q: I have been asked to build a query for a diagnosis of SIRS and/or sepsis for the following scenario: The patient was admitted for an infection urinary tract infection (UTI), pyelonephritis (PNA) and meets two SIRS criteria. The patient may be treated with oral or intravenous antibiotics, and may be on a general medical floor (not intensive care). The physician did not document SIRS or sepsis. I am having a hard time with this query because I am not sure if this would be considered adding new information to the chart or leading the physician by introducing a new diagnosis. Do you have any suggestions?
A recent salary survey conducted by our sister publication Medical Records Briefing found the same trends prevail year after year: the 145 HIM professionals who responded feel they are overworked and underpaid.
The Cooperating Parties added a 17th section to the ICD-10-PCS Manual for 2016: Section X (New Technology). Pat Brooks, RHIA, and Rhonda Butler, CCS, CCS-P, highlight how and when to use codes in this new section.
Acute kidney injury (AKI) is an abrupt decrease in kidney function that is reversible within three months of loss of function. Garry L. Huff, MD, CCS, CCDS, and Kim Yelton, RHIA, CCS, CDIP, review the clinical definition of AKI and coding for both ICD-9-CM and ICD-10-CM.
Coders and CDI specialists often rely on the encoder to determine the MS-DRG. Cheryl Ericson, MS, RN, CCDS, CDIP, reviews the steps necessary to determine the MS-DRG on your own.
Q: Can “in the setting of”' be interpreted as “due to” in ICD-10-CM? For example, the physician documented that the patient has a urinary tract infection in the setting of a urinary catheter.
ICD-10-PCS root operations Drainage, Extirpation, and Fragmentation involve removing material from the body, but in different ways. A nita Rapier, RHIT, CCS, Kristi Stanton, RHIT, CCS, CPC, and James Fee, MD, CCS, CCDS, offer tips for distinguishing between the root operations.
The optical system is the most complex organ system of the human body and is subject to specific disease processes. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer explains how to code some common eye diseases and treatments in ICD-10.
The AHA’s Coding Clinic for ICD-10 continues to provide updates and guidance for a variety of inpatient procedures, both routine and not so routine. J ames S. Kennedy, MD, CCS, CDIP, Anita Rapier, RHIT, CCS, and Sharme Brodie, RN, CCDS, highlight some important advice from Coding Clinic.
