Marianne Durling, MHA, RHIA, CDIP, CCS, CPC, CIC, an HIM director for a health system in North Carolina, provides her wish list for her department and coders, including thoughts on implementing a CDI program, working with payers, and hiring staff.
Robert S. Gold, MD, reviews conditions such as sepsis, hypertension, and syncope and how the switch to ICD-10-CM clarifies reporting codes in some instances, while other issues from ICD-9-CM remain.
The holidays can be a stressful time for coding departments, especially this year with the implementation of ICD-10. Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC, and Darice Grzybowski, MA, RHIA, FAHIMA, provide methods for HIM managers to keep coders engaged and productive this time of year and beyond.
ICD-10 implementation has gone smoothly for approximately 80% of attendees who responded to a survey during a recent webcast from audit, tax, and advisory firm KPMG.
Q: We recently had attending physicians send back queries with responses by the physician assistant (PA) or nurse practitioner (NP) who documented for them. Is it acceptable for a PA or NP to answer queries after the patient is discharged?
Linda Renee Brown, RN, MA, CCDS, CCS, CDIP, writes about the importance of tracking venous thromboembolism at hospitals and how to ensure physician documentation includes the correct level of detail to capture it.
Sherry Corsello, RHIT, CPC, writes about how to ensure consistency and reliability of records in ICD-10 and what providers can do with the more accurate data the code set will give them.
Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV) site used have to come from the physician in the progress note or can this particular information be extrapolated from nursing notes, orders, etc.? As far as I can tell, a blood transfusion is usually administered to whatever peripheral IV line/site is available, unless otherwise contraindicated or instructed differently by a specific physician order.
Coders need to understand the clinical presentation of sepsis to report it accurately. Robert S. Gold, MD, and Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, review how to identify sepsis and tips for coding it in ICD-10-CM.
CMS does not require ordering providers to rewrite orders prior to ICD-10 implementation with appropriate diagnosis codes for laboratory, radiology, and other services, including durable medical equipment, prosthetics, orthotics, and supplies, according to a new FAQ.
Garry L. Huff, MD, CCS, CCDS, and Brandy Kline, RHIA, CCS, CCS-P, CCDS, provide an overview ofkey information providers need to document for coders to assign proper codes for chronic kidney disease and acute kidney injury.
Q: Is there guidance on reviewing a record, such as an operative note, that has not been signed by a physician? I am at a facility that allows coding from unsigned transcriptions. I was always told that the information needs to be confirmed by a signature as valid before including that information in the review worksheet. Do you have any recommendations for this?
ICD-10 may be a new system with thousands of additional codes compared to ICD-9-CM, but that doesn’t mean it can still accurately report every clinical scenario. Robert S. Gold, MD, identifies conditions that aren’t necessarily represented by the codes available.
CMS finalized its proposals regarding the 2-midnight rule in the 2016 OPPS final rule, including moving responsibility for enforcement and education of the rule from Recovery Auditors to Quality Improvement Organizations (QIO). This latter change occurred October 1, 2015.
Jillian Harrington, MHA, CCS, CCS-P, CPC, CPC-P, CPC-I, MHP, reviews the components in operative reports coders will need to find in order to report ICD-10-PCS codes for spinal fusions.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about the section added to ICD-10-PCS for 2016 for reporting new technology procedures.
CMS released a new resource to help providers find the right contacts for ICD-10 questions involving Medicare and Medicaid claims. The resource guide and contact list provides phone numbers or email addresses for Medicare Administrative Contractors and state Medicaid offices for each state and U.S. territory.
Joel Moorhead, MD, PhD, CPC, and Faye Kelly, RHIT, CCS, write about the importance of clinical anatomy to coding in ICD-10 and how to best use encoders along with the code set.
