Coding a chart with a sepsis diagnosis requires careful attention to detail. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , reviews sepsis documentation, ICD-10-CM coding requirements, and quality measures for public reporting.
Ongoing labor shortages and a competitive hiring market are putting a strain on HIM departments. As competition for qualified staff increases, learn how HIM leaders can turn to a variety of short- and long-term fixes and even find opportunities for improvement.
Modifier -JW is used to describe drug amounts that are discarded and not administered to any patient. Refresh your knowledge of this modifier with coding tips and example scenarios.
Hospital coding for wound procedures is notoriously difficult, as the process can seem as messy as the injuries themselves. Clarify wound documentation and guidance for reporting wound diagnoses and procedures using ICD-10-CM, CPT, and HCPCS Level II codes.
Coding managers should not assume that they can review every coding guideline, Coding Clinic , or coding-related issue targeted by the Office of Inspector General. Review considerations for conducting focused internal and external audits.
The establishment of mandatory sepsis protocols at all hospitals in New York state is estimated to have saved more than 16,000 lives between 2015 and 2019, according to End Sepsis.
Items eligible for CMS’ New Technology Add-on Payment (NTAP) often yield high reimbursement but are prone to charging, coding, and billing errors. Learn about the NTAP designation and its impact on coding and billing processes.
A cesarean section is typically performed when complications from pregnancy make a traditional vaginal birth difficult. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , breaks down ICD-10-CM coding for common labor and delivery complications, and ICD-10-PCS coding for cesarean deliveries.
Approximately 37.3 million Americans have diabetes, and nearly 20% of them don’t know they have it, according to the Centers for Disease Control and Prevention. Review the signs and symptoms of diabetes and guidelines for reporting the condition in ICD-10-CM. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Medication Therapy Management (MTM) is a group of services provided by pharmacists that involve active management of drug therapy. Review CPT coding, the role of pharmacists, and documentation tips associated with MTM.
Q: What is the best way to determine if an E/M service is above and beyond the physician work normally associated with a procedure to justify the use of modifier -25?
Hospital coding for wound procedures is notoriously difficult, as the process can seem as messy as the injuries themselves. Clarify wound documentation and guidance for reporting wound diagnoses and procedures using ICD-10-CM, CPT, and HCPCS Level II codes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Although many provisions of the 2022 OPPS final rule are a light lift for hospitals, several have far-reaching implications. Apply these expert tips to ensure you're up to speed and aware of compliance pitfalls.
The American Medical Association (AMA) recently announced an editorial update to the CPT code set for COVID-19 vaccines that includes new codes for Pfizer-BioNTech’s booster vaccine and Sanofi-GlaxoSmithKline’s (Sanofi-GSK) vaccine candidate.
CMS is proposing to hit pause on major changes to MS-DRG designations while considering numerous changes to quality reporting and value programs, according to the fiscal year 2023 IPPS proposed rule. Read up on CMS’ proposed updates, which will impact inpatient hospitals beginning October 1. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Revenue leakage can be caused by a number of factors including late filings, inconsistent documentation, and inaccurate coding. Fran Jurcak, MSN, RN, CCDS, CCDS-O , describes proactive strategies that coding professionals can use to address mid-revenue cycle leakage.
Aspiration pneumonia is a lung infection caused by inhaled oral or gastric contents. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , breaks down documentation and ICD-10-CM coding requirements for aspiration pneumonia.
