Q: Our department has been having trouble reporting comas in ICD-10-CM. Are there any tools we can use to help us report these diagnoses more accurately?
CMS released the fiscal year 2020 IPPS proposed rule in April, which addressed various requests for MS-DRG designations, and in particular, the request for a new MS-DRG designation for chimeric antigen receptor T-cell (CAR-T) therapies that CMS subsequently denied.
Sarah Nehring, CCS, CCDS, says that from the inpatient coding and CDI perspective, sepsis can be one of the trickiest diagnoses. In this article, she reviews 10 things coders wish physicians knew about sepsis documentation and coding.
Adriane Martin, DO, FACOS, CCDS, reviews recent Coding Clinic, First Quarter 2019, advice, which includes guidance on reporting abdominal aortic aneurysm (AAA) repairs, spinal fusions, Whipple procedures, midline and central venous catheters, and more.
Peggy Blue, MPH, CCS, CCS-P, CPC, CEMC , writes that due to the frequency of diagnoses and treatments for breast cancer, it’s more important than ever for inpatient coders to make sure they are reporting these diagnoses and procedures with the utmost accuracy. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: If our physician only documents “uncontrolled diabetes” in an admitted patient’s chart, but I can see from the lab results in the record that the patient’s blood glucose levels are high, can I assign the ICD-10-CM code for diabetes with hyperglycemia?
CMS released the fiscal year (FY) 2020 IPPS proposed rule Tuesday, April 23, which included the annual ICD-10-CM/PCS code update proposals, significant changes to CC/MCC and MS-DRG designations, and a proposed increase to hospital payment rates.
Although computer-assisted coding and natural language processing software has improved many aspects of daily CDI work, the technology requires ongoing oversight to ensure efficacy and accuracy. Therefore, CDI professionals, and even inpatient coders, need to be aware of the software’s potential pitfalls within the CDI department and develop tactics to overcome them.
Gloryanne Bryant, RHIA, CDIP, CCS, CCDS , reviews the background of MS-DRGs, as frequently revising MS-DRG basics will ensure that inpatient coders have a thorough understanding of the MS-DRG intricacies, thus perfecting overall assignment and reimbursement accuracy.
Adriane Martin, DO, FACOS, CCDS, writes that treatment of peripheral arterial disease (PAD) is variable and includes both medical and surgical therapy. Given the frequency of this condition, it is imperative that inpatient coding professionals have a clear understanding of the surgical treatment of PAD to avoid costly ICD-10-PCS errors. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: Which ICD-10-PCS code should be reported for an incision and drainage of a perianal abscess of the left buttocks? We are confused about which body part value should be captured since the physician documented both “perianal” and “left buttocks.”
Kay Piper, RHIA, CDIP, CCS, details the process of submitting ICD-10-CM codes to the ICD-10 Coordination and Maintenance Committee meeting by sharing the experience a medical coding educator and a CDI physician adviser had when submitting a proposal for the March 2018 meeting.
Keeping up with changing coding guidance adds to the complexity of reporting digestive procedures. In this article, Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , reviews ICD-10-PCS reporting for common digestive procedures including the Whipple procedure and lysis of adhesions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Researchers analyzed reports and clinical data from a community hospital for malnourished patients and concluded that of the 1,817 records for malnourished adult patients examined, 1,171 (64.4%) of them were not coded for malnutrition, according to the study published in the Journal of the Academy of Nutrition and Dietetics.
Laura Legg, RHIT, RHIA, CCS, CDIP, takes a look at some common questions asked about MS-DRG optimization and reviews how inpatient coding and documentation plays a large role in the process.
Cheryl Manchenton, RN, explains CMS’ Hospital-Acquired Condition Reduction Program (HACRP) and says inpatient coding professionals can play a significant role in HACRP success by understanding the basis for hospital-acquired condition scores and ensuring that documentation and coding accurately and fully captures patient conditions and complications.
Sepsis is a leading cause of death in U.S. hospitals, but in most of cases, sepsis alone may not be the true cause of the majority of inpatient, septic hospital deaths, according to recent research published by the Journal of the American Medical Association.
Q: I know that the tumor, nodes, and metastasis (TNM) staging system can be used for ICD-10-CM coding purposes, but I’ve never used it before. As an inpatient coding professional, should I know how this system works and how to apply it?
A transcatheter aortic valve replacement (TAVR) is an interventional cardiology procedure that has proven to be an important life-saving cardiac intervention frequently seen by inpatient coders. In this article, Stephen Houlahan, RN, MSN, MBA, CCDS, reviews TAVR history, clinical background, and documentation and reimbursement methodologies to ensure proper education and compliance for facilities.
Joe Rivet, JD, CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO, writes that proper reporting and documentation of chronic obstructive pulmonary disease (COPD) will help ensure accurate MS-DRG assignment and strengthen cases during inpatient audits. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
