Nearly 80% of healthcare organizations are collecting data on social determinants of health (SDoH), or non-clinical factors that affect health, including family and home life, education, employment, and food insecurity, according to a new AHIMA survey.
Clinical documentation and ICD-10-CM coding terminology for neonatal conditions do not always match. Review documentation requirements and ICD-10-CM coding guidelines for reporting common neonatal diagnoses, as well as advice for querying pediatric healthcare providers.
Limb girdle muscular dystrophy is a group of genetic disorders that cause myopathy of the proximal shoulder and hip girdle muscles. This article reviews the disease, 2023 ICD-10-CM code updates, and relevant coding guidance. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS recently published its fourth quarter 2022 HCPCS Application Summaries and Coding Recommendations. The new codes will be used to report injections and skin substitutes and are scheduled to take effect April 1.
The American Medical Association introduced E/M updates for 2023 and there are more E/M changes scheduled for 2024, according to the CPT Editorial Summary of Panel Actions. Julia Kyles, CPC, explains several 2023 and 2024 code revisions and additions that coders would benefit from making note of in their CPT manuals.
E/M coding guidelines for emergency department services (CPT codes 99281-99285) were recently updated for the first time in decades. Hamilton Lempert, MD, FACEP, CEDC, reviews these changes, along with coding requirements for many other E/M services.
The HCPCS first quarter 2023 update, released in December, introduced several new codes and modifiers for medical products and procedural services. Most of the changes took effect January 1.
The CPT Editorial Panel made a handful of changes to codes for ocular and auditory system procedures as part of its 2023 update to the code set. This article reviews canaloplasty and auditory osseointegrated implant CPT code revisions and additions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Pam Warren-Brooks, MHA, COC, CPC, explains different types of psychiatric healthcare providers, outpatient facilities, and best practices for reporting psychiatric services using CPT codes.
Kathleen M. Romero, MSN, RN, EBP-C , Cynthia Beal, MBA-HCM, BSN, RN, and Renee Pate, MSOL, MSN Ed., RN, CCDS, explain how they implemented a CDI program in their facility’s emergency department and the how establishing this program improved coding accuracy and increased reimbursement.
Q: Would a same date admission/discharge E/M code be used for a scenario in which a patient is admitted at 11 p.m. on a Monday, is seen by the provider at 4 a.m. on Tuesday, and discharged at 8 p.m. on Tuesday?
As healthcare systems look to replicate successful CDI programs outside of large complex community or academic health centers, there are unique considerations for rural settings.
Encephalopathy refers to any disease of the brain that alters its function or structure. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG , breaks down documentation requirements and ICD-10-CM coding for toxic, acute, and chronic encephalopathy.
Chronic obstructive pulmonary disease (COPD) was the sixth-leading cause of death in the U.S. in 2020 with 152,657 deaths, according to the Centers for Disease Control and Prevention. Read up on ICD-10-CM coding for different types of COPD including emphysema and chronic bronchitis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Postoperative mortality rates among Medicare beneficiaries are associated the characteristics of patients’ neighborhoods and the hospitals where they received treatment, according to a study published in JAMA Network Open in January.
Determine whether your facility needs to change E/M documentation habits and capture different details based on the revisions made by CMS to observation and inpatient reporting in the 2023 OPPS final rule.
Remote therapeutic monitoring is one of the latest services to enter the virtual landscape since the COVID-19 public health emergency began. Debbie Jones, CPC, CCA, defines the services and reviews CPT guidance for reporting them.
Q: A 4-year-old managing lissencephaly, hypotonia, and dysphagia with aspiration of secretions presents with fever and tachypnea. A chest x-ray shows right lower lobe infiltrates. Would it be appropriate to query the provider to confirm a diagnosis of pneumonia?
Tonya Moton, RHIA, CCS, defines social determinants of health coding, explains the challenges of reporting these factors, and outlines how coders and providers can work together to create a positive impact in at-risk communities.
Findings from a recent medical record review published by JAMA Network Open show that physical assaults are often miscoded as accidents. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , breaks down ICD-10-CM coding for specific details about an injury or health event.
Chronic obstructive pulmonary disease (COPD) was the sixth-leading cause of death in the U.S. in 2020 with 152,657 deaths, according to the Centers for Disease Control and Prevention. Read up on ICD-10-CM coding for different types of COPD including emphysema and chronic bronchitis.
Jorde Spitler, RN, CDI manager at Dayton Children’s Hospital, describes key considerations for documentation review, querying, and ICD-10-CM coding in a pediatric acute care setting.
The 2023 Medicare Physician Fee Schedule (MPFS) final rule finalized major documentation and coding changes. This article summarizes new guidance for reporting E/M and telehealth services and a significant cut to physician payments.
CMS recently published an FAQ document on the use of drug waste modifiers. The resource addresses how the modifiers affect Medicare policy, to which products they can be appended, billing concerns, and more.
Q: What are the differences between remote therapeutic monitoring and remote physiologic monitoring and what details should we look for in documentation to report these services with CPT codes?
Tonya Moton, RHIA, CCS, defines social determinants of health coding, explains the challenges of reporting these factors, and outlines how coders and providers can work together to create a positive impact in at-risk communities.
This article outlines kidney anatomy, explains percutaneous nephrolithotomy and pyelolithotomy procedures, highlights relevant CPT guidance, and includes insight from experts. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Adhere to ICD-10-PCS guidance for reporting multiple procedures and procedural components when coding for wound debridement and skin grafting. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Laura Roberts, BSN, RN, CCDS , describes how to perform internal reviews that target Patient Safety Indicators, hospital-acquired conditions, and other quality indicators.
Robotic and computer-assisted surgical procedures are still considered new technology despite having been used in the U.S. for many years. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG , unpacks ICD-10-PCS coding for surgeries performed using specialized software and robotic technology.
Q: What ICD-10-PCS codes would be used to report Stage 1 of a metatarsal resection involving Excision of nonviable tissue for diagnostic purposes and partial detachment of the fifth metatarsal?
The CPT Editorial Panel released 20 new Category III CPT codes. These new codes, along with two revisions, are mainly for cardiovascular procedures and take effect July 1.
Q: When is it permissible under Medicare to assign CPT add-on code 37186 for a secondary thrombectomy when an atherectomy is performed in the same vascular territory?
This article outlines when and how to report new and revised 2023 CPT codes for arthroplasty and arthrodesis procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The end of the public health emergency (PHE) will bring the expiration of many Medicare waivers issued since 2020. Ronald Hirsch, MD, FACP, CHCQM, CHRI, explains how facilities can maintain their compliance in this new era.
Remote therapeutic monitoring is one of the latest services to enter the virtual landscape since the COVID-19 public health emergency began. Debbie Jones, CPC, CCA, defines the services and reviews CPT guidance for reporting them.
The Office of Inspector General (OIG) recently released its annual report detailing its list of top unimplemented recommendations for 2022. The agency recommends that CMS increase scrutiny of inpatient hospital claims for severe malnutrition and other diagnoses that are vulnerable to upcoding.
Pneumonia is a common infection of the lungs that can be life-threatening. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , breaks down ICD-10-CM/PCS coding for this infectious disease and its treatment.
With reimbursement gains whittled down by CMS' attempt to remedy unlawful cuts to 340B drug payments, complying with updated Outpatient Prospective Payment System (OPPS) policies is key to protecting reimbursement. Take a closer look at CMS' latest policies and ensure your organization is in compliance.
Robotic and computer-assisted surgical procedures are still considered new technology despite having been used in the U.S. for many years. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG , unpacks ICD-10-PCS coding for surgeries performed using specialized software and robotic technology.
Obesity has grown into a global epidemic with significant social and economic consequences. Review ICD-10-CM coding for obesity and other weight-related conditions, and ICD-10-PCS coding for surgical interventions used to maintain a healthy weight.
There is no single query format every organization uses. Though guidelines exist, each CDI program and its leaders must ultimately determine how to maintain compliance.
CMS developed the National Correct Coding Initiative (NCCI) to control improper coding and potentially inappropriate payment of Part B services. Review NCCI basics to ensure compliance with the latest coding policies.
Alysia Minott, CIRCC, CCS, CDIP, explains that CPT coding for complex procedures performed using interventional radiology (IR) can be mastered; the first step is learning how to interpret applicable coding guidelines.
