You may have noticed that the ICD-10 manuals have the word “draft” splashed all over them. (If you have an actual paper ICD-10 manual that is. The PDFs don’t include the word draft.) I had someone...
Welcome to OR 13 at the Stitch ‘Em Up Hospital, where Dr. Hack N. Slash is preparing for today’s procedure. And what is today’s procedure? Dr. Slash is performing a cut down and suturing of a...
Many physicians remain reluctant to admit when a complication occurs as the direct result of the medical care they provide. Trey La Charité, MD , reviews hypothetical situations to help illustrate how coders and clinical documentation improvement specialists can handle complications.
Q: The primary physician documented subacute cerebral infarction and I am wondering whether I should code this to a new cerebral vascular accident (CVA) or not, since the term “subacute” doesn’t really fall anywhere.
Coders need to understand the different approaches for procedures in ICD-10-PCS because they're required and the new system does not include default or unspecified options. Laura Legg, RHIT, CCS, Nena Scott, MS, RHIA, CCS, CCS-P, and Gretchen Young-Charles, RHIA, explain the different approaches and address gray areas for selecting the most appropriate character.
ICD-10-CM is similar to ICD-9-CM, but coders need to watch out for differences which could lead to incorrect coding. Nelly Leon-Chisen, RHIA, Gretchen Young-Charles, RHIA, and Sarah A. Serling, CPC, CPC-H, CPC-I, CEMC, CCS-P, CCS , discuss possible pitfalls for coding myocardial infarctions, neoplasms, and external causes in ICD-10-CM.
Beginning January 1, 2015, physicians will no longer need to provide certification for an inpatient admission unless the admission is expected to last for 20 days or longer or the case is an outlier.
Gerri Walk, senior manager of technical training for HRS in Baltimore, had the absolute best reason for learning to code in ICD-10. During the 2013 AHIMA National Conference in Atlanta, Gerri...
ICD-10-PCS codes consist of seven characters, each of which identifies a unique, specific piece of information. For most of the codes in the Medical and Surgical section, each character represents the same information every time.
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 an occasional article about specific anatomical locations and body parts as part of a larger series for ICD-10-CM preparation. This month's column addresses the anatomy of the thoracic cage.
Malnutrition is at its most basic level any nutritional imbalance. While it can be overnutrition, such as being overweight, obese, or morbidly obese, providers more commonly equate malnutrition with undernutrition, which is a continuum of inadequate intake, impaired absorption, altered transport, and altered nutrient utilization.
In this month's issue, we explain the clinical and coding aspects of malnutrition, review the possible approaches in ICD-10-PCS, and discuss Coding Clinic clarifications for ICD-10. Robert S. Gold reveals when to report a transbronchoscopic lung biopsy.
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician documentation to accommodate the new code set was a top concern for the healthcare industry.
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician documentation to accommodate the new code set was a top concern for the healthcare industry.
Many coders rely on the advice in the American Hospital Association (AHA)'s Coding Clinic to resolve sticky situations with ICD-9-CM coding. However, the AHA will not be transitioning its current guidance to ICD-10-CM. Instead, in January, it began focusing solely on ICD-10-CM questions to help clear up confusion prior to implementation.
Physicians use a lot of shortcuts and abbreviations. Some of them may even make it to the official abbreviation list at a hospital. Some don't. Even if they do, some physicians will use the wrong term.
Editor's note: Jugna Shah, MPH, president and founder of Nimitt Consulting, writes a bimonthly column for Briefings on APCs, commenting on the latest policies and regulations and analyzing their impact on providers.
Ghosties and ghoulies and long-legged beasties are parading through the Fix ‘Em Up Clinic. It must be Halloween and the staff Halloween party. Even the best planned Halloween party can go astray (...
Once upon a midnight dreary, as I labored on a query To send to the doc whose documentation was a source of constant woe As I nodded, nearly napping (that darn G47.411 again) Suddenly there came a...
Ewww, I don’t think so. Your feet stink. What could be causing that foul odor to emanate from your feet? The most common cause is sweat. Just sniff your old gym sneakers and you’ll see what I mean...
Coders aren’t the only ones who run into problems due to a lack of complete physician documentation. Lack of sufficient documentation also causes problems for audit review of submitted claims, which in turn leads to delays in payment, according to the October 2014 Medicare Quarterly Provider Compliance Newsletter .
Q: Do any general guidelines exist for queries on outpatient services? We are beginning the process of developing such a query system for our hospital outpatient services and clinical documentation team.
Steven Espinosa , CCS , AHIMA-approved ICD-10-CM/PCS trainer, and Denise Williams, RN, CPC-H, outline the anatomy of the upper gastrointestinal system and how anatomical details, along with the provider's approach and intent, help determine the proper procedure code.
When is a mammogram a screening procedure and when does it qualify as a diagnostic test? Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, outlines the differences between the two and what to look for in the documentation.
With the increased specificity required for ICD-10-CM coding, coders need a solid foundation in anatomy and physiology. Review the anatomy of the thoracic cage and coding concepts in ICD-10-CM related to coding diagnoses of this region.
When coders run into a tough coding question, they often look for guidance in the AHA’s Coding Clinic . Coding Clinic is a resource, but it’s not always the final word. The AHA publishes Coding...
Poor Mr. Frank N. Stein. He just coughed up a lung. Literally. While it is possible to survive on one lung, it’s generally not recommended, so Frank is here at the Stitch ‘Em Up Hospital to get a new...
If I hear one more person poke fun at ICD-10-CM code V97.33XD (sucked into a jet engine, subsequent encounter), I am going to develop a very strong case of R45.850. (That’s homicidal ideation in case...
Q: How specific does the physician have to be for the location of the acute myocardial infarction (MI) in ICD-10-CM? We don’t do catheterizations at my facility .
A large number of the code additions in ICD-10-CM appear in the musculoskeletal section. While fractures account for some of those changes, coders also need to understand how coding for other orthopedic conditions will change in ICD-10-CM. Kristi Stanton, RHIT, CCS, CPC, CIRCC, and Kim Carr, RHIT, CCS, CDIP, CCDS, discuss ICD-10-CM coding for sprains, strains, and dislocations.
Most, but not all, guidelines in ICD-10-CM match up to those in ICD-9-CM. S helley C. Safian, PhD, CCS-P, CPC-H, CPC -I, AHIMA-approved ICD-10-CM/PCS trainer, highlights some of the main guideline differences for coders to learn before the transition to ICD-10-CM.
When a physician closes off varices, coders must determine the location and method the physician used to correctly build an ICD-10-PCS code. Nena Scott, MSEd, RHIA, CCS, CCS-P, and Gretchen Young-Charles, RHIA, review the components of different procedures for closing off varices and how to code those procedures in ICD-10-PCS.
If you are a fan of American Horror Story (I’m not) or carnival sideshows (again, not my thing, but I’m not judging), you’ve seen some odd creatures. Maybe you’ve wondered if they are real. After all...
You’ve probably heard that you need to beef up your clinical knowledge for ICD-10-CM and ICD-10-PCS coding. And you’re probably wondering when you have time to do that. We’re here to help. We’ve...
Jeff, an 18-year-old male, came into the Fix ‘Em Up Clinic with complete left oculomotor palsy. Jeff stated he had a severe, throbbing headache around his eye yesterday. He took some aspirin and went...
Saturday marks the 165th anniversary of the death of Edgar Allan Poe, but sadly, we’re still not sure of the cause of Poe’s demise. We do, however, have plenty of theories. First is the popular “he...
Today we’re going to look at a real-life injury, but I will say up front that I don’t have all of the information about this particular patient’s injuries. F1 racecar driver Jules Bianchi was...
Q: My colleagues and I continually wrestle with this question: Must all diagnoses on an inpatient chart be listed in the discharge summary for them to be coded?
The four Cooperating Parties released the 2015 ICD-10-CM guidelines and, in the process, deleted a guideline that affects inpatient coding. Both the Centers for Disease Control and Prevention and CMS posted the new guidelines on their websites.
Clinical auditors are often not able to translate from ICD-9 to CPT ® to determine a procedure is inpatient-only, which leads to denials. Kimberly A.H. Baker, JD, CPC, and Beverly Cunningham, MS, RN, reveal common causes of denials and what hospitals can do to overturn incorrect denials.
The Workgroup for Electronic Data Interchange’s (WEDI) most recent survey on ICD-10 readiness included a particularly alarming (at least to me) statistic: Approximately 25% of the 324 providers who...
We’re still living under a code freeze as we (eagerly) await ICD-10 implementation. However, the four Cooperating Parties are still tweaking the ICD-10-CM guidelines. Both the Centers for Disease...
I don’t know about you, but I’m starting to feel a little like Chicken Little, yelling, “ICD-10 is coming!” instead of “The sky is falling!” And we’re all probably being met with the same polite (or...
Coding for endovascular revascularization requires following a unique hierarchy and specific guidelines. Caren J. Swartz, CPC-I, CPC-H, CPMA, CPB , and Denise Williams, RN, CPC-H , look at the anatomy of the lower body and the necessary documentation to report these services.
Changes to the codes for musculoskeletal injuries goes beyond just increased codes for fractures. Find out how to code for sprains, strains, and disclocations in ICD-10-CM.
CMS officially declared October 1, 2015, the new ICD-10 implementation date with the publication of a final rule, "Administrative Simplification: Change to the Compliance Date for the ICD-10-CM and ICD-10-PCS Medical Data Code Sets," in the August 4 Federal Register .
