Good King Wenceslas looked out on the feast of Stephen And what a festive occasion it was! Participants are suffering from: Functional dyspepsia (K30) Nausea (R11.0) Projectile vomiting (R11.12)...
Dashing through the snow, in a one-horse open sleigh … oh, wait, maybe that’s not such a good idea. Little Bobby came down with chilblains, while Suzie developed frostbite. ICD-10-CM only gives us...
Worried that your vendors won't be ready for ICD-10? CMS has a tip sheet for talking with your vendors on its website. In addition, CMS recently added five new resources: Introduction to ICD-10...
Q: How does CPT ® define "final examination" for code 99238 (hospital discharge day management; 30 minutes or less)? Does the dictation have to include an actual detailed examination of the patient? We have been coding 99238 for discharges that include final diagnosis, history of present illness, and hospital course along with discharge labs, medicines, and home instructions. Very few contain an actual exam of the patient. Have we been miscoding all this time?
In order to report accurate evaluation and management codes, coders need accurate, complete documentation. Coders can play a critical role in ensuring proper documentation. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, looks at methods coders can use to promote better documentation.
Codes for OB/GYN haven’t changed much recently, but some diagnoses still confuse coders. Glade B. Curtis, MD, MPH, FACOG, CPC, CPPM, CPC-I, COBGC , and Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, review some top areas of concern and walk through case studies to explain those problems.
In its 2014 OPPS Final Rule , CMS finalized its proposal to replace existing evaluation and management CPT ® clinic visit codes with a single HCPCS G-code.
Jugna Shah, MPH, and Valerie A. Rinkle, MPA, look at drug administration coding, beginning with documentation, in order to highlight the information coders need to ensure accuracy. They also review the hierarchy coders must follow when coding for injections and infusions.
Why in the world is Mr. Grinch so mean? Maybe the problem is his health. Let’s see if we can diagnose the Grinch’s health woes. First, he is as cuddly as a cactus. What does that mean? He’s covered...
Everybody likes a shortcut. We want to get things done faster, arrive home sooner, finish tasks more quickly. Generally shortcuts are good. Unless you’re talking about physician documentation. Then...
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: 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.
During the January injections and infusions audio conference, Jugna Shah, MPH, president and founder of Nimitt Consulting in Washington, D.C., and Valerie A. Rinkle, MPA, associate director with Navigant Consulting in Seattle, reviewed these scenarios.
Yeah, ICD-10 is all different, isn't it? Well, the appearance of the codes may change, but the diseases don't. Some things you're used to may be truly different, but what we think about while coding doesn't totally change.
Physicians are never going to like receiving queries from coders and CDI specialists. They really won't like all the queries they will receive after the transition to ICD-10.
ICD-10-PCS is a whole new ball game for inpatient coders. Everything will change. Coders have been hearing that almost constantly since CMS announced the first ICD-10 implementation date in 2009.
In this month's issue, we review injection and infusion coding guidelines, take a look at some self-administered drug clinical examples, examine knee anatomy in preparation for the increased specificity of ICD-10, and answer your coding questions.
