A complication basically refers to an unexpected result, outcome, or event. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Cheryl Ericson, MS, RN, CCDS, CDIP, and Trey La Charité, MD , detail when to report a complication and highlight the differences in complication coding between ICD-9-CM and ICD-10-CM.
The physician documented “encephalopathy” in the progress note of a patient who was admitted with a cerebrovascular accident (CVA) and/or possible seizures. James S. Kennedy , MD, CCS, CDIP, discusses what to consider when determining whether to code the encephalopathy.
Percutaneous transluminal coronary angioplasty (PTCA) is a minimally invasive procedure to open up blocked coronary arteries. Laura Legg, RHIT, CCS, AHIMA-approved ICD-10-CM/PCS trainer, Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, and Sara Clark, RHIA, MLS, AHIMA-approved ICD-10-CM/PCS trainer, explain how coders will report PTCA in ICD-10-PCS.
Poor Wendy. Shortly before Christmas, she stubbed her toe, really hard. However, no bruise appeared and her toe didn’t swell up, so she thought nothing of it. Three weeks later, she stretched her...
You have one more chance to participate in CMS’ end-to-end testing. The agency is currently looking for approximately 850 volunteers for the June 1-5 testing week. You can volunteer on your MAC’s...
Cardiovascular coding can be challenging even without the introduction of new codes and concepts in ICD-10-CM. Laura Legg, RHIT, CCS, and Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, review the anatomy of the cardiovascular system and highlight some of the key changes in ICD-10-CM.
Q: Our electronic health record system only provides for a "yes/no" choice under smoker. How can we capture the additional details necessary for an ICD-10-CM code assignment?
Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, and Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD, look at frequently diagnosed mental disordersand note changes for reporting them in ICD-10-CM.
Providers who want to volunteer to participate in CMS' final round of ICD-10 end-to-end testing have until April 17 to sign up through their Medicare Administrative Contractor's (MAC) website.
Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, discusses how to code for burns and corrosions in ICD-10-CM, which requires at least three codes to indicate the site and severity, extent, and external causes.
Liam spent this St. Patrick’s Day on a fruitless quest for a pot of gold. He powered up for his quest by having a few glasses of green Guinness beer for breakfast. Turns out it’s not a good idea to...
Poor Wile E. Coyote is headed for surgery. As you might recall, Wile E. suffered a subdural hematoma following a collision with a cliff on Friday the 13th. Dr. Frankenbean decided to try conservative...
Poor Wile E. Coyote, Friday the 13 th has not been kind to our favorite super genius. Wile E. arrived at the Acme ED decidedly the worse for wear after his latest encounter with a certain speedy bird...
Three university hospitals saw a doubling of Recovery Auditor audit activity from 2010–2011 to 2012–2013, and a nearly three-fold increase in overpayment determinations, according to a new study in the Journal of Hospital Medicine.
ICD-9-CM and ICD-10-CM differentiate between acute and chronic meniscus tears. Kristi Pollard, RHIT, CCS, CPC, CIRCC , and Gretchen Young-Charles, RHIA, review how to code these injuries in both systems.
Myths and misinformation about query practices still remain. Cheryl Ericson, MS, RN, CCDS, William E. Haik, MD, FCCP, CDIP, CDIP, and Nelly Leon-Chisen, RHIA, provide a refresher on how and when to query physicians.
Clinical documentation improvement (CDI) specialists must understand CMS pay-for-performance measures in order to improve data quality . Shannon Newell, RHIA, CCC, AHIMA-approved ICD-10-CM/PCS trainer, Steve Weichhand, and Sean Johnson explain how Patient Safety Indicator 90 is measured and what role CDI specialists play in capturing data for this measure.
Q: How should the diagnosis of urinary tract infection (UTI) and encephalopathy be sequenced, specifically which diagnosis should be the principal? If physician documentation indicates that the patient came in with confusion, can encephalopathy be assigned as the principal diagnosis if it is due to the UTI and no other contributing issues are present?
Melissa took her four nephews sledding over the weekend to the boys’ delight. They had a great time. Aunt Melissa, however, didn’t escape the adventure unscathed. While descending the (not really)...
We want physicians to be very clear in their documentation about what’s wrong with the patient and what the physician did to make that patient better. Our friends over at the Association of Clinical...
A new article in the Journal of the American Medical Association (JAMA) Psychiatry shows a strong link between genetics and autism. That’s not an unusual or completely unexpected outcome. Scientists...
Just when we were starting to feel really good about ICD-10’s chances of being implemented, AHIMA has learned that Chairman of the House Rules Committee Pete Sessions, R-Texas, is looking to draft...
Q: I have a question regarding a National Correct Coding Initiative (NCCI) edit. I reported CPT ® code 80053 (comprehensive metabolic panel) and 84132 (potassium; serum, plasma or whole blood), resulting in an NCCI conflict. This code pair does allow modifier -59 (distinct procedural service) to be appended to one of the codes to be paid for both tests. Does it matter if we append modifier -59 to the primary code or the secondary?\ In my case, sometimes the secondary code is already dropped into the system and now the edit is asking me to append the modifier. Can I add modifier -59 to 80053 whether it's the primary code or not?
The musculoskeletal and nervous system sections of the 2015 CPT Manual include dozens of new and revised codes to accommodate the latest technologies and procedures. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Peggy Blue, MPH, CPC, CCS-P, CEMC, review the codes and highlight important instructional notes in the guidelines.
Coders may be familiar with the term "fetal distress" in physician documentation, but its lack of specificity can limit code selection. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, explains what coders can look for in documentation to report the most accurate ICD-9-CM and ICD-10-CMfetal status codes.
Physician coders won't be able to just report the CPT ® code that best describes the procedure for some digestive system services in 2015. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, explain why some payers, including CMS, may require new G codes for certain procedures and how the G codes map to related CPT codes.
In this month’s issue, we offer tips to simplify coding complications, review query basics, and report on the recent Congressional hearing on ICD-10 implementation. Robert S. Gold, MD, explains when to skip the query on heart failure.
The January quarterly I/OCE update includes new modifiers, changes related to expanded packaging, and continued refinement of CMS' skin substitutes categories, but the biggest change for outpatient hospitals is the implementation of comprehensive APCs (C-APC).
The January quarterly I/OCE update includes new modifiers, changes related to expanded packaging, and continued refinement of CMS' skin substitutes categories, but the biggest change for outpatient hospitals is the implementation of comprehensive APCs (C-APC).
The implementation of Comprehensive APCs (C-APCs) in the 2015 OPPS final rule likely wasn't a huge surprise to most providers, given CMS discussed this concept in the 2014 final rule and indicated it expected to implement it the following year.
Editor's note: With the increased specificity required for ICD-10-CM coding, coders need a solid foundation in anatomy and physiology. To help coders prepare for the upcoming transition, we will provide occasional articles about specific anatomical locations and body parts as part of a larger series for ICD-10-CM preparation. This month's article addresses the anatomy of the urinary system.
The American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS) released joint physician query instructions in Guidelines for Achieving a Compliant Query Practice in February 2013.
Joe came into the Stitch ‘Em Up Hospital for a colonoscopy and therapeutic polypectomy. Once Joe was under, Dr. Ben E. Full performed a digital rectal exam, which showed good sphincter tone. Dr. Full...
The Workgroup for Electronic Data Interchange (WEDI) is conducting an ICD-10 readiness survey to find out how ready the healthcare industry is for the October 1, 2015 implementation date. Providers,...
Add another nail in the “delay ICD-10 because the industry isn’t ready” coffin. CMS d eclared its end-to-end testing week from January 26 through February 3 a success . A total of 661 volunteers...
Coders and clinical documentation specialists can use queries to improve physician documentation of a patient’s severity of illness and risk of mortality. Rhonda Peppers, RN, BS, CCDS, and Sara Baine, MSN-Ed, CCDS, walk through a case study to highlight query opportunities.
Coders and clinical documentation improvement specialists often focus on different information when reviewing documentation for heart disease. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Cheryl Ericson, MS, RN, CCDS, CDIP, highlight the different perspectives.
Q: Can CDI programs use the information on ambulance forms or trip tickets to abstract from if the information is pulled into or reiterated in the ED or history and physical (H&P) documentation? Our staff doesn’t want to miss criteria that would diminish our ability to substantiate the true severity of illness of some patients, but I have been informed that coders are not allowed to code from ambulance papers or information.
Tobie comes into the Acme ED Tuesday complaining of stomach cramps, nausea (but no vomiting), light-headedness, and chest pain. What in the world could be wrong with Tobie? Dr. H.M. Lock examines...
Quick, what’s the ICD-9-CM code for diabetes? I bet you knew it was 250.00. What’s the ICD-10-CM equivalent? Does ICD-10-CM even have an equivalent, since 250.00 is very vague? Yes, we do have a...
Debbie Mackaman, RHIA, CPCO, CCDS, discusses modifier -59 (distinct procedural service) use, including the latest guidance from CMS on the four new, more specific replacements—and how more guidance is needed before providers can feel comfortable using them.
Providers report excessive units for initial IV infusions for both chemotherapy and non-chemotherapy drugs, according to the results of an audit reported in the January 2015 Medicare Quarterly Provider Compliance Newsletter .
Q: Would it be appropriate to report CPT ® code 75984 (change of percutaneous tube or drainage catheter with contrast monitoring [e.g., genitourinary system, abscess], radiological supervision and interpretation) for the following procedure: A small amount of contrast was injected through the indwelling nephrostomy drainage catheter. This demonstrated the catheter is well positioned within the renal collecting system. There is a small amount of thrombus attached to the tip of the pigtail catheter. The existing catheter was cut and a guidewire was advanced through the catheter into the renal collecting system. The existing catheter was removed over the wire and exchanged for a new 10 French nephrostomy tube. The catheter was secured to the skin with 2-O suture and covered with a sterile dressing.
