Q: One of my coworkers thought we needed the phrase “unable to clinically determine” as an option on every multiple-choice query we send. My take on it is that if we have “other” with an option for free text, that would cover us for compliance. Further, I thought it was inappropriate to include this option in some cases, as it may offer an option that is preventing me from obtaining the detail and specificity I need.
Q: I am the coding manager for our inpatient coding department. I am wondering if I should create an audit plan to monitor new coders or difficult diagnosis. If so, is there anything specific I should consider when trying to implement a plan?
The incidence of stroke and transient ischemic attack is increasing as the baby-boomer population ages. James S. Kennedy, MD, CCS, CDIP , writes that understanding and embracing clinical and coding fundamentals for these conditions is essential in the joint effort to promote providers’ complete documentation and the coder’s assignment of clinically valid codes.
A study conducted by Journal of American Medical Association (JAMA) based on data obtained from the 2013 Nationwide Readmissions Database, revealed that sepsis accounts for a higher rate of unplanned readmissions than the other studied medical conditions.
Laura Legg, RHIT, CCS, CDIP , explains how external coding audits are an important part of shining a light into all coding operations and turning risk into security and peace of mind. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
As OPPS packaging has increased, providers may be less likely to appeal claims for certain denied charges based on medically unlikely edits, since it would not increase payments. However, providers should consider appeals when services are medically necessary and appropriate, as CMS bases future payment rates on accepted claims.
Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and sometimes vague rules.
Coders prepared for 2017 with numerous changes to the Official Coding Guidelines for the ICD-10-CM and the addition of many new codes. Quietly waiting in the wings was the updated CPT® Manual for 2017 with its changes waiting to be discovered.
In today’s ever-changing healthcare landscape, emphasis is shifting away from fee-for-service to pay-for-performance, from volume-based care to value-based reimbursement, and from case-mix index to outcome measures.
The selection of the principal diagnosis is one of the most important steps when coding an inpatient record. The diagnosis reflects the reason the patient sought medical care, and the principal diagnosis can drive reimbursement.
The human eye may be small, but it’s one of the most complex organ systems in the body. Review the anatomy of the eye and how to code for conditions affecting the system, including new details for 2017.
Q: Facilities often have two charges for services performed in an operating room (OR) suite. For example, a facility performs a colonoscopy and an esophagogastroduodenoscopy, which took a total of 20 minutes in the procedure room. The facility charged two set-up fees plus an additional five minutes of OR time. Would this be considered a duplicate charge?
The ICD-10 Coordination and Maintenance Committee will meet March 7-8 to discuss new conditions, procedures, and expanded details that could appear in a future update of the code set.
The intersection of CMS’ packaged payment policy and the increasing volume of Medically Unlikely Edits (MUE) can be likened to a car crash waiting to happen. Hospitals are having valid, medically necessary claim lines denied – including charges and units below MUE limits. Providers can help stop the crash by ensuring their claims, CPT coding, medical necessity, and the units are all correct.
With a new year underway, providers likely need to get a handle on some key new modifiers, as well as important changes to an existing modifier and the deletion of a modifier that previously raised a lot of questions and operational concerns.
Red letter days in coding compliance occurred in December 2016 and January 2017 with the Office of Inspector General’s (OIG) release of two audit reports. These reports asserted that Northside Medical Center of Youngstown, Ohio, and Vidant Medical Center of Greenville, North Carolina, improperly submitted ICD-9-CM codes for marasmus and severe malnutrition.
Q: If a patient is admitted to the hospital with diabetic ketoacidosis (DKA) and cholelithiasis, and is treated for both, would you code the cholelithiasis as the principal diagnosis because the patient had his or her gallbladder removed?
Erica E. Remer, MD, FACEP, CCDS , explains what clinical validation denials are, how they are determined, and how a coder can help to limit these rebuffs.
CMS pushed the February 15 submission deadlines for select inpatient clinical and healthcare-associated infection measure data, citing system glitches and inaccessibility to QualityNet reports.
Amber Sterling, RN, BSN, CCDS , and Jana Armstrong, RHIA, CPC , discuss revenue integrity and how it focuses on three operational pillars: clinical coding, clinical documentation improvement, and physician education.
Q: We have claims that are hitting an edit between a procedure HCPCS code and the new codes for moderate sedation (99151–99153). Since moderate sedation is no longer inherent in any procedure beginning January 1, why are these scenarios hitting an edit?
Inpatient coding departments are likely familiar with integrating clinical documentation improvement (CDI) specialists into their processes. Crystal Stalter, CPC, CCS-P, CDIP, looks at how CDI techniques can benefit outpatient settings and what services and codes facilities should target.
The codes in ICD-10-CM Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue, cover diagnoses for conditions throughout the body. Due to the wide scope of conditions in the chapter, it had extensive updates for 2017. Review some of the most significant changes and the details required to accurately report the codes.
Radiation oncology services billed to CMS had a 9.6% improper payment rate in 2015, leading to Medicare improperly paying $137 million for these services, according to a study reported in the January 2016 Medicare Quarterly Compliance Newsletter .
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, writes about the transition of the CPT code for reporting ablation of uterine fibroid tumors from a Category III to Category I code and the impact that could have on coding and billing.
Clinical documentation improvement managers discuss their management duties and program priorities and how they strive for the best possible results at their facility.
Q: My hospital’s coding team keeps having trouble distinguishing between J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection) and J44.1 (chronic obstructive pulmonary disease with [acute] exacerbation. Is there any guidance out there that can help clarify their differences? We would appreciate any help.
Crystal R. Stalter, CPC, CCS-P, CDIP, writes about how fully specified documentation is the key to quality care, compliance, and eventual reimbursement, and how documentation software can help to streamline these processes.
James S. Kennedy, MD, CCS, CDIP, discusses bundled payments and the importance of applying proper ICD-10-CM/PCS-pertinent documentation and coding principles to remain compliant.
In January, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine released the 2016 Surviving Sepsis guidelines, adopting the new consensus definitions for sepsis and septic shock (Sepsis-3) established last year.
Clinical validation denials (CVD) result from a review by a clinician, such as a registered nurse, contractor medical director, or therapist, who concludes retrospectively that a patient was not really afflicted by a condition that was documented in the medical record and coded by the coder.
With a new year underway, providers likely need to get a handle on some key new modifiers, as well as important changes to an existing modifier and the deletion of a modifier that previously raised a lot of questions and operational concerns.
The focus for clinical documentation improvement (CDI) specialists has historically been on the inpatient hospital stay. Review of the chart for conditions that are not fully documented and/or evidence of conditions not documented at all has been standard practice.
The 2017 ICD-10-CM updates included a significant number of additions to digestive system diagnoses, especially codes for pancreatitis and intestinal infections. These codes are largely focused in the lower gastrointestinal (GI) tract, and a review of the anatomy of this body system could help improve accurate documentation interpretation and code selection.
Optimal ICD-10 accuracy cannot be achieved by simply looking up a code in an encoder or book. Knowing the rationale for what you are coding, why you are applying one code versus another, and having the knowledge base to correctly apply the 2017 Official Guidelines for Coding and Reporting are the ingredients necessary for accurate clinical coding.
The 2017 ICD-10-CM Official Guidelines for Coding and Reporting brought many changes and updates for coders, and present-on-admission (POA) reporting was not excluded. Completely understanding POA guidelines is necessary for any inpatient coder.
In promoting ICD-10-CM coding integrity and compliance, cerebrovascular disease represents one of the greatest challenges for providers and coders alike. It seems that clinicians, ICD-10-CM, and risk-adjusters (those who create the DRG system), do not sing the same tune.
Q: We just heard about a new add-on HCPCS code for 2017, C1842 (retinal prosthesis, includes all internal and external components; add-on to C1841) for the Argus Retinal Prosthesis, but are not sure how to report it along with C1841 (retinal prosthesis, includes all internal and external components). It has nearly the same description as C1841, so this is confusing.
A Comprehensive Error Rate Testing study showed insufficient documentation caused most improper payments for facet joint injections, according to the January 2016 Medicare Quarterly Compliance Newsletter .
Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, reviews when coders should report modifiers -76 and -77 and notes methods for auditing a facility’s accuracy when using these modifiers.
The 2017 ICD-10-CM updates included a significant number of additions to digestive system diagnoses, especially codes for pancreatitis and intestinal infections. These codes are largely focused in the lower gastrointestinal tract, and a review of the anatomy of this body system could help improve accurate documentation interpretation and code selection.
Coders have likely noticed that the 2017 CPT Manual features big changes for reporting moderate sedation. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, writes about how to define moderate sedation and includes tips on reporting the new codes appropriately.
