James S. Kennedy, MD, CCS, CDIP, CCDS, reviews some ICD fundamentals and to help facilities develop a strategy that will ease the transition to the new administrative language as the federal government moves toward deployment of the International Classification of Diseases, 11th Edition, for Mortality and Morbidity Statistics (ICD-11-MMS).
With yearly ICD-10 code and guideline updates to the respiratory system, it’s important for coders to stay abreast of changes to ensure documentation and coding integrity. This article takes a closer look at the ICD-10-CM code updates as well as recent Coding Clinic guidance on the respiratory system. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Lynelle A. Clausen, RN, BSN, writes about the struggles she faces as a CDI specialist when dealing with vague documentation, lack of criteria, and the reporting of malnutrition.
Q: If the attending physician documented, “likely mixed cardiogenic and septic shock,” can I assign ICD-10-CM codes R57.0 (cardiogenic shock) and R65.21 (severe sepsis with septic shock)?
On January 9, CMS announced the launch of Bundled Payments for Care Improvement Advanced from the agency’s Center for Medicare and Medicaid Innovation.
Surprisingly, thyroid disease is more common than diabetes or heart disease, with an estimated 20 million Americans having some form of the disease. In this article, Yvette M. DeVay, MHA, CPC, CPMA, CIC, CPC-I gives readers a background on thyroid cancer and reviews ICD-10-CM/PCS coding for the disease.
Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, writes about the Office of the Inspector General’s (OIG) recent audit findings regarding the ICD-9-CM diagnosis code for kwashiorkor, and discusses what coders can do to stay compliant when coding guidance is lacking. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: I have a question regarding unilateral weakness from a previous stroke. The patient has ongoing weakness in both right arm and leg post cerebrovascular accident (CVA) and associated ataxia post CVA in 2013. What is the accurate code assignment?
While a facility’s case–mix index is an important metric to measure, program managers and directors warn that metrics mean different things to different stakeholders and that CDI programs need to work diligently to present their data within the context of a host of other important measures.
A report released by the American Hospital Association and Manatt Health found that facilities spend approximately $39 million annually to comply with 629 requirements across nine regulatory domains.
Victoria M. Hernandez, RHIA, CDIP, CCS, CCS-P , AHIMA-approved ICD-10-CM/PCS trainer, and Debi Primeau, RHIA, FAHIMA , highlight several areas that illustrate the increasing importance of code specificity to ensure accurate reporting and appropriate reimbursement.
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , writes that understanding the epidemiology of HIV, its manifestations, and its stages are important when reviewing the medical record for ICD-10-CM coding, and interpreting provider documentation and understanding the coding guidelines are of the upmost importance for proper sequencing.
James S. Kennedy, MD, CCS, CCDS, CDIP, interprets the various guidance given in Coding Clinic , Fourth Quarter 2017, including pre-bill audits and denials based on clinical criteria, and chronic obstructive pulmonary disease with exacerbated asthma.
Q: What would be the ideal way to code a case where a patient has ongoing encephalopathy after a subdural hematoma multiple years ago? I keep seeing documentation as a brain injury with ongoing encephalopathy, but is there a way to improve on this?
Jocelyn E. Murray, RN, CCDS, reviews the similarities and differences between CDI audits and coding compliance audits and says it’s our collective responsibility to provide the insight that defines the two specialties and the critical efforts both bring to the table.
Upon reviewing 2,145 inpatient claims at 25 providers, the Office of Inspector General (OIG) found that all but one claim incorrectly included the ICD-9-CM diagnosis code for kwashiorkor (260). This resulted in overpayments in excess of $6 million, according to the OIG report .
More than 13 million Americans have bladder incontinence, and women are twice more likely than men to have it, according to the Agency for Healthcare Research and Quality. Peggy Blue, MPH, CCS, CCS-P, CPC, CEMC, reviews ICD-10-CM/PCS coding for the bladder and writes that with so many Americans affected, knowledge of proper coding of bladder diagnoses and procedures is important.
Creating a query can be complicated, and there are a number of continued training tactics that prove successful for the coder when trying to improve upon physician query practices. This article takes a look at how improving a coder’s knowledge of principal and secondary diagnosis selection can produce a more effective physician query. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Sharme Brodie, RN, CCDS, reviews the most recent Coding Clinic guidance, which touches on common coding conundrums from subjects such as clostridium difficile, diabetes with ketoacidosis, myocardial infarction, pulmonary hypertension, and more.
Q: Can acute respiratory failure be used as the principal diagnosis rather than ICD-10-CM code I46.9 (cardiac arrest, cause unspecified) when both are present on admission?
