Reporting procedures for the skin can require a variety of documented details, such as location, severity, and size. John David Rosdeutscher, MD, and Gloria Miller, CPC, CPMA, CPPM, explainwhich details coder should look forto accurately report excisions, closures, and other wound care services.
Q: If a patient is given Reglan ® intravenously at 12:20, 13:00, and 13:20, would this be considered an IV push because the clinician did not document a stop time?
Peggy Blue, MPH, CPC, CCS-P, CEMC, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, review code changes in the 2015 CPT® Manual's Medicine section, including newly available products and services.
A Comprehensive Error Rate Testing (CERT) study of transcatheter aortic valve replacement/implantation (TAVR/TAVI) services found that approximately one third of the claims received improper payments, mostly due to insufficient documentation, according to the latest Medicare Quarterly Compliance Newsletter.
CMS is asking for some social media help in support of ICD-10. The agency is planning a social media rally to encourage the healthcare community to get ready for the ICD-10 transition. You can sign...
I’m always fascinated by new medical research and information about diseases I’ve never heard of. They also make great fodder for this blog. I recently came across an article on REM sleep behavior...
Fifteen-month-old Finn is back at the Fix ‘Em Up Clinic today to see Dr. Spock. Finn is currently suffering from a fever, reduced appetite, and sore throat, according to his mom Melissa. Finn just...
As we continue to move closer to ICD-10 implementation (still set for October 1, 2015), I keep finding more reasons why we need better documentation. I am not trying to pick on physicians (really),...
The seventh character in an ICD-10-CM code represents either the fetus (for pregnancy codes), or the encounter (for injuries and burns). Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, Gretchen Young-Charles, RHIA, and Nelly Leon-Chisen, RHIA, review guidelines for correct seventh character selection.
In ICD-10-CM, coders will use a seventh character, not an aftercare code, to identify follow-up treatment for an injury. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-DAM, Kristi Pollard, RHIT, CCS, CPC, CIRCC, and Anita Rapier, RHIT, CCS, explain how aftercare coding will change in ICD-10-CM.
The 2014 ICD-10 implementation delay negatively impacted ICD-10 preparations, according to the Workgroup for Electronic Data Interchange (WEDI) February 2015 readiness survey .
Ruth and Gary thought it would be great fun to give their nieces Amanda and Rachel some peeps for Easter. Amanda and Rachel thought they were getting marshmallow treats (so did their parents) so it...
No joke this time. We have six months left until ICD-10 implementation. That’s a good news/bad news proposition. The good news is that all of the hard work we’ve put into training and implementation...
In this month’s issue, we review some key CCs and MCCs, provide a high-level overview of PSI 90, and discuss how coding aftercare will change in ICD-10-CM, Robert S. Gold, MD, discusses hypertension in its various forms.
Mental health disorders are common in the United States, with an estimated 19% of Americans 18 or older suffering from a diagnosable mental disorder, according to a 2012 survey from the National Institute of Mental Health (NIMH).
Even through ICD-9-CM and ICD-10-CM/PCS are currently under a code freeze, c oders and CDI specialists still need to pay attention to what conditions are considered CCs and MCCs, as well as sequencing rules which could affect MS-DRGs.
Patient Safety Indicator 90 evaluates hospital performance for defined in-hospital complications and adverse events. Find out more about how clinical documentation and coding can affect this measure in the first of a four-part series.
Each year, the AMA updates the Vaccines, Toxoids section of the Medicine chapter in the CPT ® Manual to add or revise descriptions of newly available products. In 2015, the AMA added two new product codes (90651, 90630) and revised four (90654, 90721, 90723, and 90734).
One of the great things about healthcare and medicine is you can always learn something new. Today’s odd but true condition is exploding head syndrome. (I love the Internet.) If you have ever...
Jeff went on vacation to Hawaii three weeks ago to enjoy some sun, sand, and surfing. He came back with some cool photos and a broken ankle. Apparently, the parking lot at the beach did him in even...
Percutaneous transluminal coronary angioplasty (PTCA) is a minimally invasive procedure to open up blocked coronary arteries. Laura Legg, RHIT, CCS, AHIMA-approved ICD-10-CM/PCS trainer, Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, and Sara Clark, RHIA, MLS, AHIMA-approved ICD-10-CM/PCS trainer, explain how coders will report PTCA in ICD-10-PCS.
The physician documented “encephalopathy” in the progress note of a patient who was admitted with a cerebrovascular accident (CVA) and/or possible seizures. James S. Kennedy , MD, CCS, CDIP, discusses what to consider when determining whether to code the encephalopathy.
A complication basically refers to an unexpected result, outcome, or event. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Cheryl Ericson, MS, RN, CCDS, CDIP, and Trey La Charité, MD , detail when to report a complication and highlight the differences in complication coding between ICD-9-CM and ICD-10-CM.
CMS Transmittal 3217 , effective April 1, will allow inpatient-only procedures to be included on inpatient claims, similar to other outpatient services included in the three-day window.
Poor Wendy. Shortly before Christmas, she stubbed her toe, really hard. However, no bruise appeared and her toe didn’t swell up, so she thought nothing of it. Three weeks later, she stretched her...
You have one more chance to participate in CMS’ end-to-end testing. The agency is currently looking for approximately 850 volunteers for the June 1-5 testing week. You can volunteer on your MAC’s...
Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, discusses how to code for burns and corrosions in ICD-10-CM, which requires at least three codes to indicate the site and severity, extent, and external causes.
Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, and Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD, look at frequently diagnosed mental disordersand note changes for reporting them in ICD-10-CM.
Cardiovascular coding can be challenging even without the introduction of new codes and concepts in ICD-10-CM. Laura Legg, RHIT, CCS, and Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, review the anatomy of the cardiovascular system and highlight some of the key changes in ICD-10-CM.
Q: Our electronic health record system only provides for a "yes/no" choice under smoker. How can we capture the additional details necessary for an ICD-10-CM code assignment?
Providers who want to volunteer to participate in CMS' final round of ICD-10 end-to-end testing have until April 17 to sign up through their Medicare Administrative Contractor's (MAC) website.
Liam spent this St. Patrick’s Day on a fruitless quest for a pot of gold. He powered up for his quest by having a few glasses of green Guinness beer for breakfast. Turns out it’s not a good idea to...
Poor Wile E. Coyote is headed for surgery. As you might recall, Wile E. suffered a subdural hematoma following a collision with a cliff on Friday the 13th. Dr. Frankenbean decided to try conservative...
Poor Wile E. Coyote, Friday the 13 th has not been kind to our favorite super genius. Wile E. arrived at the Acme ED decidedly the worse for wear after his latest encounter with a certain speedy bird...
Myths and misinformation about query practices still remain. Cheryl Ericson, MS, RN, CCDS, William E. Haik, MD, FCCP, CDIP, CDIP, and Nelly Leon-Chisen, RHIA, provide a refresher on how and when to query physicians.
Clinical documentation improvement (CDI) specialists must understand CMS pay-for-performance measures in order to improve data quality . Shannon Newell, RHIA, CCC, AHIMA-approved ICD-10-CM/PCS trainer, Steve Weichhand, and Sean Johnson explain how Patient Safety Indicator 90 is measured and what role CDI specialists play in capturing data for this measure.
Three university hospitals saw a doubling of Recovery Auditor audit activity from 2010–2011 to 2012–2013, and a nearly three-fold increase in overpayment determinations, according to a new study in the Journal of Hospital Medicine.
Q: How should the diagnosis of urinary tract infection (UTI) and encephalopathy be sequenced, specifically which diagnosis should be the principal? If physician documentation indicates that the patient came in with confusion, can encephalopathy be assigned as the principal diagnosis if it is due to the UTI and no other contributing issues are present?
ICD-9-CM and ICD-10-CM differentiate between acute and chronic meniscus tears. Kristi Pollard, RHIT, CCS, CPC, CIRCC , and Gretchen Young-Charles, RHIA, review how to code these injuries in both systems.
Melissa took her four nephews sledding over the weekend to the boys’ delight. They had a great time. Aunt Melissa, however, didn’t escape the adventure unscathed. While descending the (not really)...
We want physicians to be very clear in their documentation about what’s wrong with the patient and what the physician did to make that patient better. Our friends over at the Association of Clinical...
A new article in the Journal of the American Medical Association (JAMA) Psychiatry shows a strong link between genetics and autism. That’s not an unusual or completely unexpected outcome. Scientists...
Just when we were starting to feel really good about ICD-10’s chances of being implemented, AHIMA has learned that Chairman of the House Rules Committee Pete Sessions, R-Texas, is looking to draft...
Physician coders won't be able to just report the CPT ® code that best describes the procedure for some digestive system services in 2015. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, explain why some payers, including CMS, may require new G codes for certain procedures and how the G codes map to related CPT codes.
Coders may be familiar with the term "fetal distress" in physician documentation, but its lack of specificity can limit code selection. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, explains what coders can look for in documentation to report the most accurate ICD-9-CM and ICD-10-CMfetal status codes.
The musculoskeletal and nervous system sections of the 2015 CPT Manual include dozens of new and revised codes to accommodate the latest technologies and procedures. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Peggy Blue, MPH, CPC, CCS-P, CEMC, review the codes and highlight important instructional notes in the guidelines.
Q: I have a question regarding a National Correct Coding Initiative (NCCI) edit. I reported CPT ® code 80053 (comprehensive metabolic panel) and 84132 (potassium; serum, plasma or whole blood), resulting in an NCCI conflict. This code pair does allow modifier -59 (distinct procedural service) to be appended to one of the codes to be paid for both tests. Does it matter if we append modifier -59 to the primary code or the secondary?\ In my case, sometimes the secondary code is already dropped into the system and now the edit is asking me to append the modifier. Can I add modifier -59 to 80053 whether it's the primary code or not?
Editor's note: With the increased specificity required for ICD-10-CM coding, coders need a solid foundation in anatomy and physiology. To help coders prepare for the upcoming transition, we will provide occasional articles about specific anatomical locations and body parts as part of a larger series for ICD-10-CM preparation. This month's article addresses the anatomy of the urinary system.
The implementation of Comprehensive APCs (C-APCs) in the 2015 OPPS final rule likely wasn't a huge surprise to most providers, given CMS discussed this concept in the 2014 final rule and indicated it expected to implement it the following year.
The January quarterly I/OCE update includes new modifiers, changes related to expanded packaging, and continued refinement of CMS' skin substitutes categories, but the biggest change for outpatient hospitals is the implementation of comprehensive APCs (C-APC).
In this month’s issue, we offer tips to simplify coding complications, review query basics, and report on the recent Congressional hearing on ICD-10 implementation. Robert S. Gold, MD, explains when to skip the query on heart failure.
The American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS) released joint physician query instructions in Guidelines for Achieving a Compliant Query Practice in February 2013.
The January quarterly I/OCE update includes new modifiers, changes related to expanded packaging, and continued refinement of CMS' skin substitutes categories, but the biggest change for outpatient hospitals is the implementation of comprehensive APCs (C-APC).
Joe came into the Stitch ‘Em Up Hospital for a colonoscopy and therapeutic polypectomy. Once Joe was under, Dr. Ben E. Full performed a digital rectal exam, which showed good sphincter tone. Dr. Full...
The Workgroup for Electronic Data Interchange (WEDI) is conducting an ICD-10 readiness survey to find out how ready the healthcare industry is for the October 1, 2015 implementation date. Providers,...
Add another nail in the “delay ICD-10 because the industry isn’t ready” coffin. CMS d eclared its end-to-end testing week from January 26 through February 3 a success . A total of 661 volunteers...
Q: Can CDI programs use the information on ambulance forms or trip tickets to abstract from if the information is pulled into or reiterated in the ED or history and physical (H&P) documentation? Our staff doesn’t want to miss criteria that would diminish our ability to substantiate the true severity of illness of some patients, but I have been informed that coders are not allowed to code from ambulance papers or information.
Coders and clinical documentation specialists can use queries to improve physician documentation of a patient’s severity of illness and risk of mortality. Rhonda Peppers, RN, BS, CCDS, and Sara Baine, MSN-Ed, CCDS, walk through a case study to highlight query opportunities.
Coders and clinical documentation improvement specialists often focus on different information when reviewing documentation for heart disease. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Cheryl Ericson, MS, RN, CCDS, CDIP, highlight the different perspectives.
Tobie comes into the Acme ED Tuesday complaining of stomach cramps, nausea (but no vomiting), light-headedness, and chest pain. What in the world could be wrong with Tobie? Dr. H.M. Lock examines...
Quick, what’s the ICD-9-CM code for diabetes? I bet you knew it was 250.00. What’s the ICD-10-CM equivalent? Does ICD-10-CM even have an equivalent, since 250.00 is very vague? Yes, we do have a...
CPT ® codes in 2015 for cardiovascular procedures include the ability to report several new technologies and procedures. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, explain the procedures and what coders will need to look for in documentation to select the correct code.
Providers report excessive units for initial IV infusions for both chemotherapy and non-chemotherapy drugs, according to the results of an audit reported in the January 2015 Medicare Quarterly Provider Compliance Newsletter .
Debbie Mackaman, RHIA, CPCO, CCDS, discusses modifier -59 (distinct procedural service) use, including the latest guidance from CMS on the four new, more specific replacements—and how more guidance is needed before providers can feel comfortable using them.
CMS' January I/OCE update brought many changes, including new codes, status indicators, and modifiers. Dave Fee, MBA, reviewsthe latest changes and when they will be implemented by CMS.
Q: Would it be appropriate to report CPT ® code 75984 (change of percutaneous tube or drainage catheter with contrast monitoring [e.g., genitourinary system, abscess], radiological supervision and interpretation) for the following procedure: A small amount of contrast was injected through the indwelling nephrostomy drainage catheter. This demonstrated the catheter is well positioned within the renal collecting system. There is a small amount of thrombus attached to the tip of the pigtail catheter. The existing catheter was cut and a guidewire was advanced through the catheter into the renal collecting system. The existing catheter was removed over the wire and exchanged for a new 10 French nephrostomy tube. The catheter was secured to the skin with 2-O suture and covered with a sterile dressing.
Ah, Fat Tuesday (AKA Mardi Gras), the last big blowout before Lent begins. For those not of a religious bent, it’s still a good reason for an all-day party. Here at the Fix ‘Em Up Clinic, we have...
My true love did his best over the weekend to make up for the 12 days’ worth of bad gift giving at Christmas. Alas, the best(?) laid plans of mice and men often go astray. My true love’s first...
Implementation costs and plans took center stage at The House Energy and Commerce Committee’s subcommittee on health’s ICD-10 Implementation hearing today. Seven witnesses testified before the...
The ICD-10-PCS Manual includes 17 different sections, including Administration. Learn how to assign codes from this section to prepare for ICD-10-PCS implementation.
Q: A patient comes in with a malunion of a fracture. A different physician treated the patient initially for the fracture, but the patient came to see our physician for surgery to repair the malunion. Which seventh character should we use: A for initial encounter or P for subsequent encounter for fracture with malunion?
Coronary artery bypass graft procedures are not the only ones coders will report using the root operation Bypass in ICD-10-PCS. Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, and Lisa Crow, MBA, RHIA, explain how to code for other bypass procedures in ICD-10-PCS.
CMS is adequately preparing to implement ICD-10 October 1, according to a new Government Accountability Office (GAO) report detailing CMS’ transition efforts.
Most coders will spend their time reporting codes from the Medical and Surgical section (first character 0) and the Obstetrics section (1). Each character in those sections has the same meaning:...
“Practice makes perfect” is a well-known adage. How many people can do any new task requiring specific skills successfully without practicing? We can’t consider the transition to ICD-10-CM/PCS...
Don’t look now, but Congress is examining ICD-10 implementation again. The House Energy and Commerce Committee’s subcommittee on healthcare will hold a hearing at 10:15 a.m. Wednesday, February 11 ,...
Curious about how CMS’ end-to-end testing for ICD-10 is going? Want to know how you can sign up? CMS is hosting a National Provider Call on ICD-10 implementation and Medicare testing from 1:30-3 p.m...
Eighty-four percent of providers experienced no major problems with early ICD-10 acknowledgement testing, according to a recent AAPC survey of more than 2,000 providers.
Q: Is it correct to append modifier -52 (reduced services) to a procedure code when the physician performed the procedure, but did not find a mass? This was unexpected, so the surgeon went deeper into the subcutaneous tissue and still did not find anything. This is the outpatient note for a patient with a history of breast cancer and a new lump on her arm with an indeterminate ultrasound: Under local anesthesia and sterile conditions, a vertical incision was made over the area of the palpable abnormality. We dissected down beneath the subcutaneous tissues. I could encounter no definitive mass or lesions in this area. We went down to the fascia of her bicep. Her biceps appear normal, and the skin and subcutaneous tissue appear normal. My presumption is that this represented some sort of venous anomaly, and I either popped it or incised it during our entry into the skin, and it is now resolved. Would CPT ® code 24075-52 (excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; less than 3 cm) be correct to report?
Drug administration coding and billing remains a challenge despite no code changes in six years. Jugna Shah, MPH, and Valerie RInkle, MPA, examine how to apply the new -X{EPSU} modifiers with drug administration codes and review other common questions they receive about injections and infusions.
In the 2015 OPPS final rule, CMS introduced a new modifier for services provided in an off-campus, provider-based clinic. Jugna Shah, MPH, and Valerie Rinkle, MPA, review when the modifier will become required and how it should be reported.
The AMA added a new CPT ® code for chronic care management. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, writes about the time and documentation requirements for reporting this service.
And a chilly one it is. It’s also the day after the Super Bowl, which means patients with a variety of injuries arrived at the Fix ‘Em Up Clinic today. First is Phil, who is convinced he is a...
In this month’s issue, we examine how coders and CDI specialists look at chest pain, review the most recent Coding Clinic advice on ICD-10-PCS , and explain how querying can lead to a more accurate representation of a patient’s severity of illness and risk of mortality. Robert S. Gold, MD, discusses whether coders should report every diagnosis mentioned in a patient’s chart.
Coding professionals may inappropriately assign codes from parts of the medical record where the doctors, early in the workup of a complex patient, were describing differential diagnoses in their evaluation of the patient. Robert S. Gold, MD, discusses whether coders should report every diagnosis mentioned in a patient’s chart.
