Q: We know that we can look at the radiology report to get some specifics about a fracture. When it comes to an open fracture in ICD-10-CM, can you determine the Gustilo-Anderson classification, whether it's I, II, IIIA, IIIB, or IIIC, based on a description of the wound? Or does the physician actually have to document, “It's a Gustilo type I" or "type III”?
Coders use different codes to report traumatic and pathologic fractures. Robert S. Gold, MD, and Kristi Stanton, RHIT, CCS, CPC, CIRCC, highlight the differences in coding for the two etiologies of fractures in both ICD-9-CM and ICD-10-CM.
Inpatient coders and clinical documentation improvement specialists are very familiar with CCs and MCCs. After all, they help determine the MS-DRG assignment for a particular inpatient stay. ICD-10-...
Put on your deerstalker hat and grab your magnifying glass. It’s time to do our best Sherlock Holmes impersonation. We just received a chart from Dr. Doolittle and we need to code the procedure...
Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, details correct coding for spinal injuries in both ICD-9-CM and ICD-10-CM, along with the documentation requirements for choosing the most accurate code.
Injuries to the elbow and forearm are common as a result of many everyday activities, and ICD-10-CM allows more specificity for reporting these conditions. Review the anatomy of the elbow joint and forearm to prepare for ICD-10-CM.
The July quarterly I/OCE update from CMS brought few new APCs or edit updates, but did deliver a new modifier. Debbie Mackaman, RHIA, CHCO, Jugna Shah, MPH , and Denise Williams, RN, CPC-H , explain how to use the modifier, as well as the impact of APC changes.
Q: A patient comes into the ED with sickle cell crisis and is in a lot of pain. The physician states the patient needed “aggressive” pain control for treatment, because what was given in the beginning provided only minimal relief. Could I code using CPT ® code 99285 (ED visit for evaluation and management of a patient, including a comprehensive history, comprehensive exam, and high complexity medical decision making)?
Insufficient documentation led to approximately 97% of improper payments for kyphoplasty and vertebroplasty claims reviewed during a recent Comprehensive Error Rate Testing (CERT) study, according to the Medicare Quarterly Provider Compliance Newsletter.
Julie comes into the Fix ‘Em Up Clinic with a seriously broken arm. Her son Jay left his toy fire engine on the stairs and Julie tripped over it. She threw her arms out to brace her fall. And then...
Have you started dual coding for ICD-9 and ICD-10? Two facilities shared their experiences today during the AHA’s webinar, Lessons Learned on Dual Coding–A Provider’s View. The first thing you need...
As part of the 2015 OPPS proposed rule , released July 3, CMS is considering eliminating the requirement for a signed physician certification for most short inpatient stays. CMS would still require a signed physician certification for stays that last 20 days or longer, as well as outlier cases.
The complexity of coding rules and the quality of documentation in facilities sometimes make correct DRG assignment a daunting task. Laura Legg, RHIT, CCS, highlights current DRGs that are subject to Recovery Auditor scrutiny and provides tips for accurate DRG assignment.
Chronic kidney disease (CKD) is a manifestation of many different chronic disease processes, including diabetes, hypertension, and immune complex diseases. Garry L. Huff, MD, CCS, CCDS , and William E. Haik, MD, FCCP, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, explain the clinical indicators of CKD as well as coding and documentation problem areas.
CMS designates certain procedures as inpatient-only, meaning it will only reimburse the facility when the procedure is performed on an inpatient. However, CMS identifies these procedures using outpatient CPT ® codes. Beverly Cunningham, MS, RN, and Kimberly A.H. Baker, JD, CPC, discuss the process for identifying and coding inpatient-only procedures.
It turns out that not all eponyms are going away in ICD-10-PCS. The Alphabetic Index still includes an entry for a Roux-en-Y operation. The entry directs you to see bypass of the gastrointestinal...
Q: We are coding for pain management procedures and have been doing dual coding in ICD-9-CM and CPT ®. With a medial branch block ablation at two levels for L3-L4 and L4-L5 for a bilateral injection, we are coding: ICD-9-CM procedure code 04.2 (destruction of cranial and peripheral nerves) CPT codes 64635 (destruction by neurolytic agent, paravertebral facet joint nerve[s], with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single facet joint) and 64636 (destruction by neurolytic agent, paravertebral facet joint nerve[s], with imaging guidance [fluoroscopy or CT]; lumbar or sacral, each additional facet joint [List separately in addition to code for primary procedure]), each with modifier -50 (bilateral procedure) appended. What would be your recommendation for the ICD-10-PCS code? Currently we are coding 015B3ZZ (destruction, lumbar nerve, percutaneous) twice. We are not sure if we should be picking this code up twice or only once.
The 2015 OPPS proposed rule , released July 3 by CMS, is relatively short at less than 700 pages, but contains refinements to the previously introduced Comprehensive APC policy and significant packaging of ancillary services.
Body mass index (BMI) reporting is becoming more important as a diagnostic tool for providers, and ICD-10-CM will expand the ability to accurately report it. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , looks at documentation concerns and coding concepts for BMI in both ICD-9-CM and ICD-10-CM.
ICD-10-CM expands the coding options for phobias, eating disorders, and pervasive developmental disorders. Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD , reviews these disorders and how to report them in ICD-10-CM.
Coders will find many more options for fractures in ICD-10-CM. Review the anatomy of the foot and the specificity providers will need to document to code accurately with the new code set.
Holly spent the weekend hanging out at the beach, enjoying the sun. The sand was so warm that she slipped off her shoes to stroll near the water. And disturbed a crab in the process. The crustacean,...
A lot of people are starting their Fourth of July celebrations early. At least it seems that way at the Fix ‘Em Up Clinic. Shannon took her dog Damian to the park to watch some fireworks last night...
Go to your local bookstore, pick up a copy of Gray’s Anatomy (the book, not the television show), and flip though the illustrations. Alternately, you can Google “Gray’s anatomy illustrations.” They...
CMS' introduction of the 2-midnight rule in the 2014 IPPS final rule makes properly identifying inpatient-only procedures even more important for hospitals.
ICD-10-PCS will be a big change for inpatient coders. The best way to learn the new coding system is to practice, practice, practice. See how well you know ICD-10-PCS by assigning all applicable ICD-10-PCS codes for the following case.
In this month's issue, we explain how to identify inpatient-only procedures, discuss ways to educate physicians about how quality of their documentation reflects the quality of their care, and provide an ICD-10-PCS case study to test your knowledge. Dr. Robert Gold reviews the various types of diverticula.
Documentation and billing for observation stays has come under increased scrutiny from the OIG, though many hospitals have struggled with changing regulations and frequently updated guidance.
Physician documentation drives quality measures, but physicians often don't understand how the quality of their documenation relates to their quality of care.
Documentation and billing for observation stays has come under increased scrutiny from the OIG, though many hospitals have struggled with changing regulations and frequently updated guidance.
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 feet.
CMS and Obamacare have increasingly been moving healthcare toward a more value-based model. They want to pay physicians for how well they treat patients and not by the volume of services they provide...
More healthcare providers would have been ready for an October 1, 2014 ICD-10 implementation date than people may have realized, according to a survey by Edifecs, eHealth Initiative (eHI) and AHIMA...
Composers lead pretty safe lives, right? They compose music, conduct the symphony, and hang out at post-show parties. And we’re not talking rock star parties. Sometimes, though, that job isn’t so...
The increased specificity required for ICD-10 coding requires a solid foundation in anatomy and physiology for coders. Review the anatomy of the kidney, as well as the essential coding concepts to properly report kidney conditions in ICD-10-CM.
Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I , examines common orthotic procedures, including fracture reduction, total knee replacement, and total hip replacement, to determine how to choose the correct CPT ® code and key terms that should be documented.
Q: I work for general surgeons. Here is a common scenario: The surgeon is called in to see patient in the ED for trauma or consult. The patient is admitted, but our physician is not the admitting physician. I would tend to bill the ED code set, but do I have to use the subsequent hospital care codes instead?
Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS , and Susan E. Garrison, CHCA, CHCAS, PCS, FCS, CPC, CPC-H, CCS-P, CHC, CPAR, examine a pair of case studies to determine whether the right codes were applied and whether it's appropriate to append a modifier.
Poor Finn is having a rough week. It started out well as he spent Sunday with his folks and older brother at an amusement park being as amused as a 6-month-old can be. Things started going downhill...
Jeff comes in to the Fix ‘Em Up Clinic complaining of shortness of breath, a persistent cough, tightness in his chest, and frequent respiratory infections. He tells Nurse Nosey that he smokes a pack...
CMS focused on quality measures in the 2015 IPPS proposed rule, released April 30. Kimberly A.H. Baker, JD, Cheryl Ericson, MS, RN, CCDS, CDIP, James S. Kennedy, MD, CCS, CDIP ,and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, highlight the most significant proposed changes.
Learning to code in ICD-10-PCS is in some respects like learning a language, you need a strong foundation in the rules. Sue Bowman, MJ, RHIA, CCS, FAHIMA , Gerri Walk, CCS-P , Nena Scott, MSEd, RHIA, CCS, CCS-P , and Jennifer Avery, CCS, CPC-H, CPC, CPC-I, discuss the guidelines related to root operations in ICD-10-PCS.
Sequela, or late effect, is the remaining or lasting condition produced after the acute stage of a condition or injury has ended. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, reviews the correct way to code for sequelae in ICD-9-CM and ICD-10-CM.
Q: A few days into the patient’s stay, an order for a Foley catheter was placed for incontinence and around the same time the physician documented a urinary tract infection (UTI). Would it be appropriate to query the physician regarding the relationship of the UTI to the Foley? Our infection control department caught this but we did not. I am concerned about this for two reasons; first, I worry about writing a leading query and second, whether the UTI could be considered a hospital-acquired condition (HAC) if additional documentation isn’t provided.
