Q: Can CDI programs use the information on ambulance forms or trip tickets to abstract from if the information is pulled into or reiterated in the ED or history and physical (H&P) documentation? Our staff doesn’t want to miss criteria that would diminish our ability to substantiate the true severity of illness of some patients, but I have been informed that coders are not allowed to code from ambulance papers or information.
The ICD-10-PCS Manual includes 17 different sections, including Administration. Learn how to assign codes from this section to prepare for ICD-10-PCS implementation.
Coronary artery bypass graft procedures are not the only ones coders will report using the root operation Bypass in ICD-10-PCS. Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, and Lisa Crow, MBA, RHIA, explain how to code for other bypass procedures in ICD-10-PCS.
Q: A patient comes in with a malunion of a fracture. A different physician treated the patient initially for the fracture, but the patient came to see our physician for surgery to repair the malunion. Which seventh character should we use: A for initial encounter or P for subsequent encounter for fracture with malunion?
CMS is adequately preparing to implement ICD-10 October 1, according to a new Government Accountability Office (GAO) report detailing CMS’ transition efforts.
A hiatus from Recovery Auditor scrutiny may have allowed HIM professionals to focus on other issues, but Laura Legg, RHIT, CCS, explores why HIM departments need to gear up for Recovery Auditors’ return.
In order to identify patients with a CC or MCC, coders need to know when to report additional diagnoses. William E. Haik, MD, FCCP, CDIP, and Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, discuss when to report a secondary diagnosis.
Q: When atelectasis is noted on an ancillary test such as a CT scan of the abdomen or chest x-ray, can nursing documentation of turning, coughing, and deep breathing be considered an intervention that qualifies as one of the criteria to meet a secondary diagnosis?
Accurately painting a picture of the patient's severity of illness (SOI) and risk of mortality (ROM) is essential for good patient care, and it is becoming increasingly important for quality measures and reimbursement. Sara Baine, MSN-Ed, CCDS, and Rhonda Peppers, RN, BS, CCDS , explain the importance of accurately reporting conditions that affect SOI and ROM.
Physician documentation for the use of osteogenic stimulators for nonunion of fractures is often insufficient for Medicare coverage, according to Comprehensive Error Rate Testing (CERT) results .
In some cases, coding professionals can—and should—report ancillary services provided to inpatients. Denise Williams, RN, CPC-H, and Valerie A. Rinkle, MPA, explain when and how to bill for ancillary bedside services.
Auditors continue to scrutinize inpatient wound care services. Glenn Krauss,BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, reviews the importance of documenting medical necessity for these services.
The reason a patient comes in is to a facility not always the same as the reason the physician admitted the patient. Brush up on the guidelines for principal diagnosis selection.
The District of Columbia federal district court dismissed a lawsuit December 18, 2014, filed by the American Hospital Association (AHA) against HHS for excessive and inappropriate Recovery Auditor denials, according to AHA News. The AHA announced that it may appeal the court’s decision.
The anatomical definition of a body part may not be the same as the ICD-10-PCS identification of a body part. Jennifer Avery, CCS, CPC-H, CPC, CPC-I, Nena Scott, MSEd, RHIA, CCS, CCS-P, and Gretchen Young-Charles, RHIA, explain the guidelines for selecting the appropriate body part and how body parts can affect root operation selection.
Q: If the physician writes septic shock instead of sepsis, do I need to query for sepsis? Is this an integral part of the diagnosis and sepsis would be the principal diagnosis, with septic shock a secondary diagnosis, making it an MCC?
CMS Transmittal 547 changes the audit timeframe for complex reviews from 60 to 30 days for some MAC and Recovery Auditor reviews. The change could significantly affect the volume and timeliness of complex reviews for providers. The transmittal becomes effective February 24, 2015.
