Most, but not all, guidelines in ICD-10-CM match up to those in ICD-9-CM. S helley C. Safian, PhD, CCS-P, CPC-H, CPC -I, AHIMA-approved ICD-10-CM/PCS trainer, highlights some of the main guideline differences for coders to learn before the transition to ICD-10-CM.
The four Cooperating Parties released the 2015 ICD-10-CM guidelines and, in the process, deleted a guideline that affects inpatient coding. Both the Centers for Disease Control and Prevention and CMS posted the new guidelines on their websites.
Clinical auditors are often not able to translate from ICD-9 to CPT ® to determine a procedure is inpatient-only, which leads to denials. Kimberly A.H. Baker, JD, CPC, and Beverly Cunningham, MS, RN, reveal common causes of denials and what hospitals can do to overturn incorrect denials.
Q: My colleagues and I continually wrestle with this question: Must all diagnoses on an inpatient chart be listed in the discharge summary for them to be coded?
Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests, but they all come back normal. In the discharge note, the physician documents “abdominal pain, gastroenteritis versus irritable bowel syndrome (IBS).” When I first started as a CDI specialist I was told we could not use diagnoses when "versus” was stated, and that we had to query for clarification.
If coders choose the wrong root operation in ICD-10-PCS, they will arrive at an incorrect code. Nena Scott, MSEd, RHIA, CCS, CCS-P, AHIMA-approved ICD-10-CM/PCS trainer, Gretchen Young-Charles, RHIA, Anita Rapier, RHIT, CCS, and Nelly Leon-Chisen, RHIA, discuss some of the root operation clarifications offered by Coding Clinic .
ICD-10 implementation and coding present plenty of challenges, especially when it comes to ICD-10-PCS. Sue Bowman, RHIA, CCS, and Donna Smith, RHIA, clear up some misconceptions about ICD-10 implementation and use.
Recovery Auditors have uncovered incorrect secondary diagnoses in patients who underwent amputations for musculoskeletal and circulatory system disorders. CMS revealed the findings in its Quarterly Compliance Newsletter .
Not feeling well? The problem could be in your small intestine. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, reviews common conditions related to the small intestine.
Q: We’re having a lot of discussions with physicians right now and need to get some clarity on acute cor pulmonale versus chronic. Do you have any insight on that differentiation between the two with right-sided heart failure, chronic obstructive pulmonary disease (COPD), shortness of breath, and edema?
ICD-10-PCS root operations Control and Repair are used when a procedure doesn’t really fit into a different root operation. Nena Scott, MSEd, RHIA, CCS, CCS-P, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS , discuss when coders should use these two root operations.
The 2015 IPPS final rule focused on quality measures. James S. Kennedy, MD, CCS, CDIP, and Cheryl Ericson, MS, RN, CCDS, CDI-P, highlight the changes and explain the role of coding in quality scores.
In part 2 of his series on medical necessity and coding, Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, examines medical necessity and the 2-midnight rule using a case study.
Heart failure is one of the top MS-DRGs, so Recovery Auditors have focused on identifying potential coding problems with MS-DRGs 291, 292, and 293. Recovery Auditors identified errors related to sequencing of the principal diagnosis and improper coding of secondary diagnoses, according to the Medicare Quarterly Compliance Newsletter .
CMS proposed a major change to physician certification requirements in the 2015 OPPS proposed rule. Kimberly A.H. Baker, JD and James S. Kennedy, MD, CCS, CDIP, break down how the change could affect inpatient admissions.
Q: How would the following be viewed if it was included in a cardiology consult note: Mr. Jones has paroxysmal atrial fibrillation. He had a recurrence last night which was asymptomatic. We think this happens all the time at home. This is not a pacing post-conditioning (PPC). He is back in normal sinus rhythm (NSR). I would restart his warfarin if Dr. Smith will allow. Goal International Normalized Ratio (INR) is 2-3.
The Official ICD-9-CM Guidelines for Coding and Reporting talk about the perinatal and newborn period as being the first 28 days of life. Robert S. Gold, MD, explains when neonatal really is—and isn’t—neonatal.
Spinal fusion is a procedure to join, or fuse, two or more vertebrae and can be performed in both the inpatient and outpatient settings. Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, MCP, review spinal anatomy before discussing correct ICD-9-CM Vol. 3 and ICD-10-PCS coding for inpatient spinal fusions.
The section of codes that expanded most in ICD-10-CM involves orthopedic injuries, especially fractures. Kim Carr, RHIT, CCS, CDIP, CCDS , and Kristi Stanton, RHIT, CCS, CPC, CIRCC, highlight some of the most significant changes for fracture coding.
