Q: I am never sure of correct sequencing when the admission is for flu, pneumonia, and asthma. The patient presented in the emergency department (ED) with shortness of breath, still tight after nebulizer treatment in the emergency room. The patient was kept for observation for one day, then was admitted. Documentation includes: Fever 101.8 in ED; respiratory rate (RR) 24; white blood cell count (WBC) 12.6 Influenza and upper respiratory tract infection Mild persistent asthma in exacerbation due to the above (wheezing, tachycardia in the ED, 130s); acute hypoxic respiratory failure (PO 90%). Superimposed RLL community-acquired pneumonia (CAP), per chest x-ray Can you suggest proper sequencing and if queries are needed?
After an almost five-month deferment, the Beneficiary and Family Centered Care Quality Improvement Organizations resumed initial patient status reviews of short stays in acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities, CMS announced on their website.
Q: I am with a CDI program that is starting to explore severity of illness/risk of mortality (SOI/ROM). I personally have been reviewing for SOI/ROM for quite a while. I usually designate the impact (MCC/CC/SOI/ROM) after the billing is done and see if what I queried for made a final impact, and only take credit for those that do. I was told that regardless of the actual final impact on SOI/ROM, we should be taking credit for any SOI/ROM clarification as SOI/ROM impact. Which is the most accurate, “correct” way to capture the CDI impact for these types of clarifications?
Since the physician doesn't need to document a specific root operation, coders cannot rely solely on the terms the physician uses; thus it is important for each coder to fully understand each root operation, including Restriction and Occlusion. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Laura Legg, RHIT, CCS, CDIP , explains how the coming months will prove to be challenging for coders because of the new ICD-10 codes for both diagnoses and procedures beginning October 1. Along with that, we’ll see the end of the CMS grace period on code specificity for Part B physician payments and updated ICD-10-CM Official Coding Guidelines .
Laurie L. Prescott, MSN, RN, CCDS, CDIP , writes that as many CDI teams work to expand their risk adjustment programs, a melding of two skill sets, that of CDI specialists and coding professionals, are required to succeed.
Q: The coders at my facility have started automatically linking congestive heart failure, hypertension, and chronic kidney disease (CKD) to the combination code without any documentation of CHF “due to” hypertension. There is no documentation of hypertensive heart disease anywhere in the record, and the diagnoses are not linked anywhere in the record.
CMS released a national coverage determination recently covering a percutaneous left atrial appendage closure through their “coverage with evidence development” policy. CMS says this policy will be fully implemented on October 3, 2016.
Sharme Brodie, RN, CCDS , discusses how to decipher between some potentially confusing—and possibly conflicting—information regarding diabetes documentation requirements.
Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer, writes that the majority of the 2017 IPPS final rule updates are consistent with those outlined in the proposed rule, but contain a few refinements. She reviews refinements to the number of claims-based outcomes linked to payment.
Accurately reporting altered mental status and encephalopathy can be a challenge that requires coordination between coders and providers. James S. Kennedy, MD, CCS, CDIP, explains best practices for coding these tricky conditions. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Q: During an ICD-10-PCS Fusion, when a physician documents the use of a “structural allograft spacer” in the medical record, what sixth character would we use when coding this? Some colleagues say to use A (interbody fusion) and some say to use K (nonautologous tissue substitute). What would be the correct way to code this?
Richard D. Pinson, MD, FACP, CCS , discusses the new Sepsis-3 definition and how the classification has been the subject of great controversy and consternation since its publication in The Journal of the American Medical Association.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP , writes about how computer-assisted coding software can be used to boost coding accuracy and productivity, in addition to being an important tool for the remote coder.
A study conducted by Johns Hopkins Armstrong Institute for Patient Safety and Quality finds that common measures used by government agencies and public rankings to rate the safety of hospitals, such as the Agency for Healthcare Research and Quality’s patient safety indicators, and hospital-acquired conditions, do not accurately capture the quality of care provided.
Robert Stein, MD, CCDS, and Shannon Newell, RHIA, CCS, co-author this article that provides insights into how clinical documentation and reported codes may impact payments and offer guidance on some common CDI challenges to strengthening data quality. Note: To access this free article, make sure you first register if you do not have a paid subscription.
James Kennedy, MD, CCS, CDIP , offers his take on AHIMA’s recently published clinical validation practice brief. Given that AHIMA is one of the ICD-10 Cooperating Parties, their practice briefs must be read closely, and if agreeable, incorporated into one’s compliance plan. Note: To access this free article, make sure you first register if you do not have a paid subscription.
CMS released the fiscal year 2017 IPPS final rule August 2. ICD-10-CM/PCS code changes and the addition of the Medicare Outpatient Observation Notice had a starring role in the final rule.
Shannon Newell, RHIA, CCS, writes about recently proposed modifications to Patient Safety Indicator 90, and how a fact sheet released by the measure's owner, the Agency for Healthcare Research and Quality, provides insights into what changes may lie ahead.
