Katy Good, RN, BSN, CCDS, CCS, Paul Evans, RHIA, CCS, CCS-P, CCDS, Laurie Prescott, MSN, RN, CCDS, and Gloryanne Bryant, BS, RHIA, CDIP, CCS, CCDS, all comment on how over-querying is a common concern in clinical document improvement, and how over-querying can cause delays in documentation and coding processes.
Kimberly Anderwood Hoy Baker, JD, writes about the many changes in the 2017 IPPS proposed rule, and explains how almost everyone could be affected by CMS’ proposals.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, reviews scenarios for initial, subsequent, and sequela encounters, and helps coders better understand how to assign seventh characters for each type of encounter. Note: To access this free article, make sure you first register if you do not have a paid subscription.
The American Health Information Management Association has officially responded to proposed ICD-10-CM/PCS codes that were presented at the ICD-10 Coordination and Maintenance Committee meeting held in March by CMS.
The FY 2017 IPPS proposed rule addresses MS-DRG classifications and relative weights pertaining to the categories of other cardiothoracic procedures without MCC, and injuries, poisonings and toxic effects of drugs.
With a widespread lack of awareness of national best practice guidelines for malnutrition, Joannie Crotts, RN, BSN, CPC , and Szilvia Kovacs, MS, RD, LDN , explain how identifying and diagnosing the condition is often still difficult, and how important changes can be made to improve a facility’s malnutrition program.
CMS issued the fiscal year 2017 IPPS proposed rule on April 18, and has proposed changes to the Medicare Code Editor software program based on numerous provider requests.
Robert S. Gold, MD, writes about important changes made in hypertension since ICD-9-CM, and helps coders better understand the relatively complex diagnosis.
Q: We are currently using a hybrid medical record, so we have standard query forms with multiple-choice options that cannot be modified at this time. We wanted to include a statement so our query doesn’t seem leading. Is our approach to the multiple-choice query format appropriate?
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, discusses strategies for reporting, and better understanding, pyeloplasty in ICD-10-PCS. Note: To access this free article, make sure you first register if you do not have a paid subscription.
ICD-10-PCS defines the root operations in very specific ways and coders need to know the definitions and the nuances of the root operations. Learn more about root operations that involve the physician looking at a patient, Inspection and Map.
Q: We have a teenager with systemic lupus erythematosus and history of lupus nephritis who came into the ED with seizures. The physician admitted the patient with documentation of with status epilepticus and hypertensive urgency. The intensivists then documented hypertensive encephalopathy. What should we choose as the principal diagnosis?
Anny Pang Yuen, RHIA, CCS, CCDS, CDIP and Laurie Prescott, MSN, RN, CCDS, CDIP discuss how for the past few years, healthcare professionals have focused on ICD-10 preparation, and while prep work paid off and the transition has been largely successful, facilities are experiencing a few bumps as their focus shifts from preparation to improvement of clinical documentation and coding.
Robert S. Gold, MD, writes about the significant changes in documentation needs for diseases of the brain and how this can affect patient data, as well as the treatment needs of the patients both during a hospital stay and afterward.
CMS issued the fiscal year 2017 IPPS proposed rule yesterday with updates to several quality initiatives and a reversal of the agency’s 0.2% payment reduction instituted along with the 2-midnight rule in the FY 2014 rule.
When the Quality Improvement Organizations (QIO) took over the role of education and enforcement for the 2-midnight rule on October 1, 2015, many anticipated that their reviews would only look at records from that date forward, but some hospitals have reported QIO record requests zeroing in on cases as far back as May 2015 and requesting charts for inpatient-only surgeries.
An infographic newly released by CMS guides healthcare providers toward better assessing, addressing, and maintaining progress since ICD-10 implementation. Identifying key performance indicators and creating baselines for KPI analysis are important steps in tracking progress, says CMS.
Q: We are having trouble determining how to assign a code for a pressure ulcer that begins as a Stage I concern that is present on admission (POA) but advances during the patient’s stay to a Stage II or a Stage III. Coding Clinic, Fourth Quarter 2008, p. 194, tells us that even if the ulcer advances it would still be coded as POA, but would even an advanced stage still be considered POA?
Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer, explains how under the Comprehensive Care for Joint Replacement, acute care hospitals in selected geographic areas assume quality and payment accountability for retrospectively calculated bundled payments for lower extremity joint replacement episodes, and how this now requires a CDI evolution.
