CMS has repeatedly tweaked its logic regarding comprehensive APCs since inception. Dave Fee, MBA, reviews the latest changes regarding complexity adjustments, as well as new and deleted codes.
Bacteria are everywhere. Literally. And you can’t see them or feel them. In fact, trillions of them are living on your skin right now. So not all bacteria are bad. Some, though, can do nasty things...
It's great, identifying opportunities to teach. Whenever I do medical record audits, I always look for chances to educate coders, physicians, and/or CDI specialists about areas of misunderstanding by coding professionals or elements of patient experience that require specific documentation for proper code assignment.
Ask a physician why he or she documents in the medical record and you'll get a variety of answers. Some physicians will say they document because the medical records people hound them for the information, or they do it so they get paid. They may also say they do it to complete the medical record.
ICD-10-PCS root operations Excision and Resection differ only in how much of a body part is removed. Review these situations to clarify which root operation to report.
Although CMS did not propose any changes to the 2-midnight rule in the fiscal year 2016 IPPS proposed rule, it signaled its intention to address short stays in the calendar year (CY) 2016 OPPS proposed rule. CMS followed through by introducing several proposed changes to the 2-midnight rule.
In this month's issue, we speak with physicians about queries in ICD-10-PCS and look at some specialty-specific procedures that may require queries. We offer tips on how to differentiate between ICD-10-PCS root operations Excision and Resection and review the changes CMS proposed to the 2-midnight rule. Robert S. Gold, MD, reveals how to use audit findings to your advantage.
Physician groups have led much of the resistance against ICD-10 implementation. At its June Delegates meeting, the AMA approved a resolution from W. Jeff Terry, MD, for a two-year grace period to protect physicians from errors and mistakes related to the code set. Terry also authored an AMA resolution to delay ICD-10 in November 2011, which led to postponing implementation until October 1, 2014.
We're less than four months away from the implementation of ICD-10-CM/PCS, and the AHA Coding Clinic for ICD-10-CM/PCS is rolling right along with advice for the new code set.
Alex comes in to see Dr. Guts complaining of fatigue and tiredness, as well as some slight abdominal pain. After performing a complete exam and blood tests, Dr. Guts diagnoses Alex with a bleeding...
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.
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.
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?
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.
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.
CMS offered some clarity on what it considers to be a family of codes in ICD-10-CM. You might remember that CMS struck a deal with the American Medical Association (AMA) to get AMA on board with ICD-...
Leprosy cases are surging in Florida, with new cases in the first half of 2015 nearing the average total for an entire year. The potential source of this explosion (to use the term very loosely) of...
