Q: In ICD-10-PCS, which root operation would we report for an obstetrical delivery? Would it change for a cesarean section versus a manually assisted vaginal delivery?
In ICD-10-PCS, coders will need to find details they currently don’t use. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, offers tips for locating the necessary information in the body of the operative report.
CMS released version 31 of the MS-DRG grouper for ICD-10 in November. Providers can use the grouper to identify MS-DRG shifts and payment changes under ICD-10. The Final ICD-10 MS-DRG v32 logic, which will be implemented on October 1, 2014, will be subject to rulema
Q: Can you ask a yes or no question in a query based on clinical information from a previous echocardiogram report or other diagnostic result from a previous admission?
The audit landscape continues to change as Recovery Auditors expand prepayment reviews and CMS implements its new 2-midnight rule. Debbie Mackaman, RHIA, CPCO, Ralph Wuebker, MD, MBA, and Kimberly Hoy Baker, JD, review some of the recent changes to audit focus areas.
Problems can occur anywhere along the alimentary canal or in any of the accessory organs. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, discusses some common diagnosis and procedure codes for digestive diseases and procedures.
Documentation and medical necessity continue to be scrutinized by payers and auditors. Debbie Mackaman, RHIA, CPCO, and Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, explain how complete, accurate documentation of the entire patient encounter justifies the physician’s decision to admit.
CMS created a 2-midnight presumption and benchmark as part of the 2014 IPPS Final Rule as a way to clarify its guidelines for inpatient admission. However, the American Hospital Association (AHA) and American Medical Association (AMA) believe the clarification creates more confusion.
Q: What recommendation would you give to the coder when the clinical indicators in the chart do not support sepsis but it’s in the final diagnostic statement?
Some hospitals are incorrectly reporting lymphoma and leukemia MS-DRGs for patients who are admitted and treated for anemia and dehydration, according to the Medicare Quarterly Provider Compliance Newsletter .
Clinical queries serve a definitive purpose when documentation in the medical record is ambiguous, inconsistent, lacking specificity, or contradictory. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, explains why documentation improvement initiatives and heightened coder awareness of the need to query can be an asset or liability.
Coders may find assigning codes for sepsis somewhat easier in ICD-10-CM, but they will still face some challenges. Ann Barta, MSA, RHIA, CDIP , and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CCDS, detail how to report sepsis in ICD-10-CM.
When an error occurs in coding, sometimes the coders miscodes a record, but in others, the documentation is deficient, leading to incorrect code assignment. Joy Strong, PMP, Donielle Bailey, RHIA, and Jill M. Young, CPC, CEDC, CIMC, discuss how good documentation and accurate coding go hand in hand.
Physicians believe they are providing quality care, which gives them high job satisfaction. However, the problems associated with using electronic health records decreased that satisfaction, according to a recent RAND survey.
The ICD-10 implementation will result in a slowdown at every level of coding. Elaine O’Bleness, MBA, RHIA, CHP, Migdalia Hernandez, RHIT, Kimberly Carr, RHIT, CCS, CDIP, and Rachel Chebeleu, MBA, RHIA, provide suggestions on how to minimize that productivity decline.
A wound is an injury to living tissue caused by a cut, blow, or other external or internal factor. Robert S. Gold, MD , and Gloria Miller, CPC, CPMA , review anatomy and documentation for wounds and explain how to code for wound care in ICD-9 and ICD-10.
Recovery Auditors are data mining for sepsis MS-DRGs and then focusing in on those with a short length of stay. Robert S. Gold, MD, and Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, provide tips for correct sepsis coding to avoid auditor takebacks.
The ICD-10-PCS Official Guidelines for Coding and Reporting address four specific circumstances when coders will report multiple procedures. Jennifer Avery, CCS, CPC-H, CPC, CPC-I, and Mark N. Dominesey, MBA, RN, CCDS, CDIP, HIT Pro-CP, explain the guidelines and how they differ from the current ICD-9-CM guidelines.
