Q: I would like to add encephalopathy due to urinary tract infection to our quick coding tips, but our CDI specialists disagree on how this condition should be coded and want us to query for metabolic encephalopathy. How should this condition ultimately be reported?
The Office of Inspector General (OIG) has been conducting a series of studies about adverse events in various healthcare settings since 2008 and will be publishing more of its corresponding reports throughout 2019, the OIG said in a statement.
Adriane Martin, DO, FACOS, CCDS, writes that with the complexity of malnutrition—and the complexity of updated criteria—even the most seasoned inpatient coder should review ICD-10-CM malnutrition coding guidelines and criteria frequently to ensure compliant reporting.
CMS recently made several updates in its latest version of its Hierarchical Condition Category (HCC) list, including revisions to the mental health and chronic kidney disease categories. And, while HCCs may not be a common review focus for inpatient coders and CDI professionals, capturing HCCs for these conditions is paramount for accurate reporting and reimbursement.
Assigning the appropriate ICD-10-PCS code for spinal procedures can be a challenge for inpatient coders as they need to correctly identify each character of the seven-character code. In this article, Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS , offers coding tips for reporting spinal surgery cases in ICD-10-PCS and examines the correct use of each character. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: A physician documented that a pregnant patient is obese, and the patient’s chart has a listed body mass index (BMI) score. Can we assign an ICD-10-CM BMI code in this instance or should this never be done for an obstetrics patient?
The original DRG system aimed to categorize similar patients with theoretically similar treatments and charges based on the patient’s principal diagnosis and up to eight secondary diagnoses. As time has gone by this system has expanded and become more complicated, making it essential for inpatient coders to understand to ensure accurate reporting and facility reimbursement.
A preliminary study found that a new point-of-care troponin assay safely ruled out acute myocardial infarction (AMI) in a large proportion of patients with symptoms suggestive of acute coronary syndrome, according to the report published in the Journal of the American Medical Association.
Q: Considering the fiscal year 2019 update to the ICD-10-PCS Official Guidelines for Coding and Reporting for Transfer procedures, how should we now report a pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedure in ICD-10-PCS?
Sepsis has been notoriously hard to report in ICD-10-CM, which means coders should not only fully understand coding guidance and guidelines for sepsis, but they should also have a thorough knowledge of its clinical aspects as well. Cesar M. Limjoco, MD , breaks down these clinical aspects and sheds light on the various sepsis definitions coders have encountered over the years.
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , writes that while reporting mental illness is on the radar for outpatient coders, inpatient coders should be up to date with these diagnoses as well. Capturing this data in the inpatient setting not only substantiates reimbursement, it is also used to identify national trends for tracking and understanding these serious conditions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Sarah Humbert, RHIA, and Catrena Smith, CCS, CCS-P, CPCO, CPC, CIC, CPC-I, CRC, CHTS-PW, explore three scenarios for onboarding new inpatient coders and provide valuable advice to prepare them for success.
Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS, review the recently published “Global Leadership Initiative on Malnutrition (GLIM) Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community” and help coders apply this criteria in ICD-10-CM.
CMS and the Office of Inspector General (OIG) claims to have identified unspecified upcoding in hospital billing—either accidentally or intentionally reporting higher severity codes than supported by documentation to increase payment. Because of this, these entities will conduct a two-part study to assess inpatient hospital billing, according to the OIG.
As the task of query creation is becoming more prevalent in coding departments, reviewing essential query requirements is a must for all inpatient coders. This article covers these essential requirements including the growing adoption of electronic medical records, when to query, and pointers for submitting queries to physicians. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS, writes that by reviewing common electronic health record (EHR) challenges, a CDI program can formulate appropriate mitigation strategies to minimize potential negatives of the system.
Adriane Martin, DO, FACOS, CCDS, explains the confusion behind the various sepsis definitions and provides guidance to coders when reporting sepsis in ICD-10-CM.
For patients who suffer from frequent symptoms of gastroesophageal reflux disease (GERD), the provider may have to increase to prescription strength medications and possibly consider surgical intervention for severe cases. In this article, Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, HCS-D, reviews ICD-10-CM/PCS coding for these GERD diagnoses and procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
