Program for Evaluating Payment Patterns Electronic Report compares hospital data regarding a variety of benchmarks. John Zelem, MD, FACS, and Brenda Hogan, RN, BS, explain how hospitals can use PEPPER to identify risk areas and create a plan for self-auditing.
By now, you probably know that ICD-10-PCS codes contain seven alpha-numeric characters. Each character represents a specific piece of information and those meanings can vary by section. In the...
If you have looked at the ICD-10-PCS Manual, you know that the codes are arranged in tables based on the first three characters of the code. The table contains all of the possible choices for...
Physicians and facilities use the same codes to report evaluation and management (E/M) levels for emergency department (ED) services, but follow different rules. Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, and Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, explain how to correctly choose the most appropriate E/M code for ED services.
CMS is proposing two major changes as part of the 2013 OPPS proposed rule, released July 6. One has to do with how CMS proposes to calculate APC relative weights; the other addresses the reimbursement level for separately payable drugs and biologicals without pass-through status. Jugna Shah, MPH, and Debbie Mackaman, RHIA, CHCO, discuss the proposed changes for OPPS payment.
Providers will now soon need only one unique health plan identifier when billing insurance companies. CMS finalized the Administrative Simplification: Adoption of Standard for Unique Health Plan Identifier rule released August 24.
QUESTION: I work in an urgent care setting and need to know if we can bill an administration code for injection of Toradol. For example, a patient comes in, and the provider performs an E/M and administers 60mg Toradol intramuscular. I have not been charging for it, thinking it’s bundled into the E/M.
Labor Day might mark the unofficial end of summer, but we have plenty of summer-related injuries today at the Fix ‘Em Up Clinic. Our first guest of the day, James, went rock climbing for the first (...
In this month's issue, we review the proposed changes in the 2013 OPPS proposed rule, compare coding for diabetes in ICD-9-CM, ICD-10-CM, and answer reader questions.
Many coders can quickly quote the code for diabetes mellitus in ICD-9-CM (code 250.00) when the physician only documents diabetes mellitus. But what will coders need in the documentation for diabetes mellitus in ICD-10-CM? Dissect the differences in coding for diabetes mellitus in ICD-9-CM and ICD-10-CM.
Do you audit records before sending them to your Recovery Auditor? If not, your hospital may be one of many that simply don't have the resources to do so.
Our coding experts answer questions about reporting dialysis for ESRD patient in ED, coding for sequential infusions, procedures on the inpatient-only list, replacement code for C9732, and new drug HCPCS codes.
Information received by TMF Quality Institute during the past year indicates that 61% of hospitals use PEPPER data to guide their auditing process and help them focus on areas of potential vulnerability.
Learn about ICD-10-CM stroke and coma codes, how coding and clinical terminology differences make coding complications difficult, why code evolution is sometimes for better and sometimes for worse, how self-audits benefit the Recovery Audit process, how PEPPER benefits an audit program, and how to help physicians understand what coders need.
Coding managers and their team members sometimes must approach physicians in person regarding documentation. Clarification may be necessary, or perhaps you will need to coax the physician to complete certain records without further delay.
CMS is proposing two major changes as part of the 2013 OPPS proposed rule, released July 6. One has to do with how CMS proposes to calculate APC relative weights; the other addresses the reimbursement level for separately payable drugs and biologicals without pass-through status.
Welcome to Stitch ‘Em Hospital, where we’re preparing for ICD-10-PCS by actually coding some of our procedures using the new system. We want to make sure we’re ready to go on October 1, 2014, and...
HHS will delay implementation of ICD-10 by one year, from October 1, 2013, to October 1, 2014. HHS announced the delay as part of the Administrative Simplification: Adoption of a Standard for a Unique Health Plan Identifier; Addition to the National Provider Identifier Requirements; and a Change to the Compliance Date for the International Classification of Diseases, 10thEdition (ICD-10-CM and ICD-10-PCS) Medical Data Code Sets final rule released August 24.
Neoplasm coding in ICD-10-CM is similar to the current ICD-9-CM coding. Most benign and all malignant neoplasm codes are found in chapter 2 of ICD-10-CM, just as in ICD-9-CM, according to Betty Hovey, BA, CPC, CPC-I, CPC-H, CPCD, CCS-P, PCS, CCP, CIC, RMC. She explains some of the ICD-10-CM guidelines for proper coding.
Retain. Train. Assess. Investigate. Analyze. HIM professionals have undoubtedly come across action verbs like these since HHS announced the replacement of the ICD-9-CM code set with the more advanced ICD-10-CM code set currently used in other nations. Mark Jahn, Luisa Dileso, RHIA, MS, CCS, and James S. Kennedy, MD, CCS, CDIP, explain what HIM professionals need to do over the next two years to be ready for the final implementation date of October 1, 2014.
ICD-9-CM and ICD-10-CM stroke and coma codes reveal many similarities and some important differences. Alice Zentner, RHIA, and James S. Kennedy, MD, CCS, CDIP, explain the changes and what coders need to know to prepare for ICD-10-CM stroke and coma coding.
We’ve all heard of deranged killers, but have you ever heard of a deranged knee? Better yet, can you code for it? Coding for a derangement isn’t new. We have derangement codes in ICD-9-CM. For...
HHS will delay implementation of ICD-10 by one year, from October 1, 2013 to October 1, 2014. HHS announced the delay August 24 as part of the Administrative Simplification: Adoption of a Standard...
Penny came into the Fix ‘Em Up emergency department Friday, complaining of tingling and numbness in her face and arm. She was also somewhat unsteady on her feet. Her husband Dave also reported Penny...
Q. When is it appropriate to append modifier -74 (procedures discontinued after anesthesia administration or after the procedure has begun) or -73 (procedures discontinued prior to anesthesia) instead of to modifier -52 (reduced service)? Is there more than anesthesia that determines their use? The report below was coded with CPT ® 62311 (injection[s] of diagnostic or therapeutic substance[s]…; lumbar or sacral [caudal]). I asked the coder if modifier -74 should be appended, and the coder said that -52 should be appended. Is this correct? Procedure: Attempted lumbar midline interlaminar epidural steroid injection L5-S1 with fluoroscopy After identifying the L5-S1 interlaminar space fluoroscopically, the skin was sterilely prepped and draped. The skin and subcutaneous tissue were anesthetized with 1% lidocaine. Utilizing a loss of resistance technique and intermittent fluoroscopic guidance, an 18 gauge Tuohy needle was utilized to approach the epidural space. I was not able to successfully identify the epidural space secondary to encountered resistance. The needle depth was checked on lateral views and noted to be superficial to the epidural space when resistance was encountered. We were going to utilize a caudal approach, however skin breakdown was noted. At this point, I elected to have her return for care in 2 weeks and get the skin breakdown in the caudal area treated.
Coders face many challenges when coding for services provided by teaching physicians, interns, residents, and students. Medicare has specific rules and regulations surrounding what services it will pay for when an intern, a resident, or a student provides services. Lori-Lynne A. Webb, CPC, COBGC, CCS-P, CCP, CHDA, details what coders need to see in the documentation before reporting these services.
Some wounds and conditions don’t respond to conventional therapies and treatment modalities. In those cases, providers may consider hyperbaric oxygen therapy (HBO). Gloria Miller CPC, CPMA, and Todd Sommer, DO, DPM, CWS, review the conditions eligible for HBO therapy and correct code assignment for these services.
When is in appropriate to use modifier -59 to override coding edits? When is another modifier more appropriate? Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, and Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS , explain the appropriate use of modifier -59.
We’ve hit the middle of August and Anytown’s summer adult baseball league is winding down its season. Just like the pros, though, our players haven’t escaped injury free. Randy, the league’s top...
What do cubism and coding have in common? Both can be viewed as art forms. Joel Moorhead, MD, PhD, CPC, details the three steps that the coding artist performs in reassembling medical record elements into abstracted form.
Q: A patient has been diagnosed with peritonsillar cellulitis and oropharyngeal cellulitis. The physician documents that he performed a “needle aspiration of the left peritonsillar abscess.” In the body of the operative report, the physician states, “An 18-gauge needle was inserted and 1 cc of pus was aspirated. This was sent for aerobic, anaerobic, C&S [culture & sensitivity], and gram stain. I then put the 18-gauge needle in again and multiple passes were obtained without any aspirate.” Because ICD-9-CM does not include a code for “aspiration of peritonsillar abscess” some coders wanted to use ICD-9-CM procedure code 28.0 (incision and drainage of tonsil and peritonsillar structures) while others want to report code 28.99 (other operations on tonsils and adenoids). Which code is correct?
CMS officially announced the Recovery Auditor prepayment review demonstration in November 2011, but then in January 2012 decided to delay the program by three months. Since then—despite rumors that the program could be coming soon —the official start date has been unknown to the public. This changed however, when CMS announced Friday, August 3, that Recovery Auditor prepayment reviews will begin August 27.
Physicians often use the acronyms IBS (which should indicate irritable bowel syndrome) and IBD (which should indicate inflammatory bowel disease) interchangeably even though they represent completely different conditions with different treatment and prognoses. Robert S. Gold, MD, and Drew K. Siegel, MD, CPC, offer tips on how to decipher documentation related to these two conditions.
Diseases of the ear and mastoid process are moving up in the ICD-10-CM world. They’re getting their own chapter. In ICD-9-CM, eyes and ears shared a section. You’ll find diseases of the ear in...
We’re one step closer to knowing whether the Department of Health and Human Services (HHS) will actually delay ICD-10 implementation and if so, by how long. The Office of Management and Budget (OMB)...
The dogs days of summer have arrived so the residents of Anytown descended on the dog park with their furry friends today. Sadly, not all of the puppies (and people) play well together and some of...
As part of the July update to the Intergrated Outpatient Code Editor, CMS reinstated HCPCS C1882 to the list of acceptable devices for CPT code 33249. Dave Fee, MBA, explains the implications of the change and reviews code changes included in the update.
Physicians can perform three different types of wound debridement and coders will find different codes for each type. Gloria Miller, CPC, CPMA, and John David Rosdeutscher, MD, discuss the different types of debridement, as well as coding and documentation requirements.
Inpatient facilities received mixed news on proposed changes to the list of complications and comorbidities (CC) and major CCs (MCC) in the fiscal year (FY) 2013 Inpatient Prospective Payment System (IPPS) final rule , released August 1.
Observation services can generate so much confusion that CMS actually asked for comments on observation and inpatient status as part of the 2013 OPPS proposed rule. Kimberly Anderwood Hoy, JD, CPC, and Deborah K. Hale, CCS, CCDS, help coders unravel the complexities of observation services.
QUESTION: A patient complained of intractable pain from compression fracture (sustained the day prior to admission). The guidelines state if pain is not documented as acute or chronic, don't assign codes from the 338 category. Should we query the physician if the pain was acute or chronic rather than just using the fracture code if it appears that pain control was the main reason for the visit?
When a physician places a device that takes the place of all or some of a body part, assign a code from ICD-10-PCS root operation replacement (third character R). Think of a total knee replacement or...
Patience may be a virtue, but knowledge is power. Okay, enough clichés. The bottom line is we’re still waiting for a new ICD-10 implementation date. HHS published the proposed rule, moving...
Learn about documentation and principal diagnoses, coders and EHR implementation, clarifying IBS and IBD for accurate code assignment, and ICD-10 fracture codes.
A lack of funding shouldn't prevent you from getting creative in your morale-boosting celebrations, according to Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, and Nicolet Araujo, RHIA. So when your staff members are around, this time of year can be a great time to boost their morale with summer outings and special staff recognition for jobs well done.
There is nothing new about stress; humans have felt stress since the beginning of time, and coders are certainly no exception. Lois Mazza, CPC, discusses how coders can mitigate the many effects of stress while they handle the pressures of their jobs and lives.
Physicians often use the acronyms IBS (which should indicate irritable bowel syndrome) and IBD (which should indicate inflammatory bowel disease) interchangeably even though they represent completely different conditions with different treatment and prognoses.
Coders can run into two types of edits that may require them to append modifier -59 (distinct procedural service) to override: NCCI edits and medically unlikely edits (MUE).
In this month's issue, our coding experts answer questions about how to differentiate between modifiers -52, -73, -74, coding for negative pressure wound therapy, and billing the technical component of pathology services.
Coding for physician services doesn’t always match coding for facility services, which can cause problems for coders who code records for both. ED E/M is one area where different rules come into play.
In this month's issue, we unravel confusion surrounding use of modifier -59, explain the difference between NCCI and MUE coding edits, discuss building E/M ED visit level, review the updates to the I/OCE, and answer reader questions.
The sheer number and detail of new fracture codes in ICD-10-CM is daunting, leaving many coders to wonder-and worry-about whether physicians will document the information they need to assign the correct codes.
QUESTION: I'd like to address our coders' questions on how to code poisoning due to bath salts. Internet research has led me to many different options: codes 977.8 (other specified drug/medicinal), 970.89 (other CNS stimulant), 969.70 (psychostimulant, unspecified), among others. What would you suggest? There don't seem to be any guidelines out there and the coding for this seems to be all over the place.
HCPCS code C1882 (cardioverter-defibrillator, other than single or dual chamber [implantable]) will once again meet the criteria to override the device-to-procedure edit for CPT® code 33249 (insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead[s], single or dual chamber).
CMS released its latest MLN Quarterly Provider Compliance Newsletter, volume 2, issue 4 in July. The newsletter addresses common billing and coding errors, with the latest issue addressing frequently cited Recovery Auditors and Comprehensive Error Rate Testing (CERT) findings.
A surgeon performs a diagnostic shoulder arthroscopy before repairing a patient’s rotator cuff. The surgeon knew ahead of time that he or she would be repairing the rotator cuff. Should a coder or biller append modifier -59 (distinct procedural service) to the CPT® code for the diagnostic shoulder arthroscopy to ensure reimbursement for both procedures?
What happens in Vegas might stay in Vegas, but when things go wrong in Atlantic City, people end up at Fix ‘Em Up Clinic. Today, we have several bachelor party victims who made the clinic their first...
Why hello there, Mr. Coyote. Long time, no see. Are you still chasing that roadrunner? You are? Well, you are certainly persistent, I’ll give you that. So what brings you into the Acme Clinic today?...
The American Osteopathic Association (AOA) House of Delegates has joined the American Medical Association’s (AMA) crusade to crush ICD-10 implementation. Back in November 2011, the AMA’s House of...
Many coders can quickly quote the code for diabetes mellitus in ICD-9-CM (code 250.00) when the physician only documents diabetes mellitus. But what will coders need in the documentation for diabetes mellitus in ICD-10-CM? Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Jill Young, CPC, CEDC, CIMC, and Donna Smith, RHIT, dissect the differences in coding for diabetes mellitus in ICD-9-CM and ICD-10-CM.
The National Center for Health Statistics, the Centers for Disease Control and Prevention (CDC), and CMS have posted updated files for ICD-10-CM for 2013.
Cross-training coders has definitive short-term advantages, such as enhancing staff coverage during holidays and vacations and increasing the department's ability to handle periods of fluctuation in certain bill types. But coding managers might not realize that these benefits can also help hospitals with long-term preparation for ICD-10. Angie Comfort, RHIT, CCS, and Rose T. Dunn, MBA, RHIA, CPA, FACHE, explain the benefits of cross training coders as ICD-10 approaches.
Over the weekend, Matt decided to grill up dinner, which sounds at first like a good idea. He started with chicken, then added some vegetables, unfortunately including some cherry tomatoes. While he...
Epilepsy affects nearly 3 million Americans and 50 million people worldwide, so you may see some of these patients come through your facility or practice. In ICD-9-CM, you find many of the epilepsy...
The National Center for Health Statistics, the Centers for Disease Control and Prevention, and CMS have posted some updated files for ICD-10-CM for 2013. The following files are available for...
I grew up in Western Pennsylvania coal country, where coal mines at one time were prevalent and back in the day, you could smell the hydrogen sulphide (at least according to my mother). A lot of the...
QUESTION: A patient is admitted with pneumonia and atrial fibrillation and both are present on admission. The patient receives antibiotics for the pneumonia and a pacemaker during the stay, but undergoes no other procedures. Does the procedure automatically make ICD-9-CM code 427.31 for the atrial fibrillation the principal diagnosis?
The digestion process is complex and there’s a lot that can go wrong. Thankfully, Robert S. Gold, MD, unravels the topic of mechanical and paralytic ileuses in this week’s article.
New clinical guidelines for malnutrition could help alleviate compliance challenges associated with coding the condition, which has never had universally accepted clinical criteria. Jane White, James S. Kennedy, MD, CCS, CDIP, and Alice Zentner, RHIA, describe the new guidelines and what coders need to know about malnutrition coding.
The thought of learning ICD-10 is intimidating for many coders, but does it need to be? Robert S. Gold, MD, and Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, explain why coders may not need to fear the transition quite as much as they think.
In late May, CMS released nationwide a new short-term (ST) acute care Program for Evaluating Payment Patterns Electronic Report (PEPPER). The ST PEPPER provides short-term acute care hospital (STACH) statistical data for the most recent 12 federal fiscal quarters, ending with the first quarter of fiscal year 2012.
We’re having a heat wave, a tropical heat wave, here at Anytown, which means the Fix ‘Em Up Clinic is seeing plenty of heat-related illnesses. Meredith, our first patient, comes in complaining of a...
In ICD-10-PCS, coders will only report a device when the device remains in the patient after the procedure. If it’s removed, it’s not a device and your sixth character will be Z. For many procedures...
Does even the mere thought of coding in ICD-10-CM give you a pounding headache? Well, you’re in luck. ICD-10-CM has plenty of codes for reporting that headache. In order to code for a headache, we...
CMS is proposing two major changes as part of the 2013 Outpatient Prospective Payment System (OPPS) proposed rule , released July 6. One has to do with how CMS proposes to calculate APC relative weights and the other with the reimbursement level for separately payable drugs and biologicals without pass-through status.
Coders can run into two types of edits that may require them to append modifier -59 (distinct procedural service) to override: National Correct Coding Initiative (NCCI) edits and medically unlikely edits (MUE). Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS, and Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, explain the differences between the edits and how to correctly determine when to override the edit.
QUESTION: Our laboratory medical director sent out a notification to our medical staff, patient care departments, and order entry personnel that a physician order that read “CBC” or “CBC with differential” would be completed as a CBC with automated or manual differential and coded using CPT ® code 85025 (blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC, and platelet count] and automated differential WBC count). Should we code 85025 when the order just reads CBC and when we do a manual differential with the CBC?
Pain is an expected component of injuries, illnesses, and surgical procedures. In some instances, however, the patient's pain is unexpected or is worse than predicted. Sometimes, the pain can last well beyond the time it should have resolved. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, and Susan E. Garrison, CHCA, CHCAS, CHC, PCS, FCS, CCS-P, CPAR, CPC, CPC-H, provide tips and guidance to help coders accurately report pain management diagnoses and procedures.
An anesthesia provider faces plenty of challenges: cancelled anesthesia, failed medical direction, monitored anesthesia care, time issues, invasive line placement rules, and start/stop times. Judy A. Wilson, CPC, CPC-H, CPCO, CPC-P, CANPC, CPC-I, CMRS, reviews some of the common challenges coders face when reporting anesthesia services.
One advantage to using ICD-10-PCS is increased specificity. Coders will find increased specificity for the procedure, approach, device, and even anatomical region or body system. In the Medical and...
The eyes are the windows to the soul, but even the best windows can get cloudy or scratched or suffer some other type of trauma. Suppose a patient comes in with cloudy vision. The patient could be...
Pain is an expected component of injuries, illnesses, and surgical procedures. Let's face it, breaking your leg hurts. In some instances, however, the patient's pain is unexpected or is worse than predicted. Sometimes, the pain can last well beyond the time it should have resolved.
Our coding experts answer your questions about correct use of modifier –PD, coding infusions to correct low potassium levels, payment for HCPCS code J2354, appropriate reporting of IV push followed by infusion of the same drug, and the difference between modifiers –AS and -80.
ICD-10-CM coronary artery disease and myocardial infarction codes will undoubtedly differ from their ICD-9-CM counterparts in some ways, but some aspects will remain the same.
A physician can debride a wound to remove dead, damaged, or infected tissue so the remaining healthy tissue can better heal. Coders need to look for specific information in the documentation of wound debridement.
In this month's issue, we examine pain management diagnosis and procedure coding, reveal how to differentiate between types of wounds when coding, explain how to read an operative report, and address your coding questions.
To correctly assign codes for any surgical procedure, coders need to have an operative (OP) report. But simply having the OP report isn't enough. Coders also must be able to read the report and pick out the important information.
Learn about ICD-10-CM coronary artery disease and myocardial infarction codes, three-day payment rule audits, malnutrition clinical guidelines, the causes of mechanical and paralytical ileuses, and the importance of documenting the history of present illness.
New clinical guidelines for malnutrition could help alleviate compliance challenges associated with coding the condition, which has never had universally accepted clinical criteria.
