Drainage procedures can be therapeutic in nature or diagnostic, such as when a physician removes a fluid or gas for biopsy. A nita Rapier, RHIT, CCS, Nelly Leon-Chisen, RHIA, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS , highlight the differences in coding diagnostic and therapeutic thoracocentesis and lumbar tap procedures in ICD-10-PCS.
Acute kidney injury (AKI) is an abrupt decrease in kidney function that is reversible within three months of loss of function. Garry L. Huff, MD, CCS, CCDS, and Kim Yelton, RHIA, CCS, CDIP, review the clinical definition of AKI and coding for both ICD-9-CM and ICD-10-CM.
The Cooperating Parties added a 17th section to the ICD-10-PCS Manual for 2016: Section X (New Technology). Pat Brooks, RHIA, and Rhonda Butler, CCS, CCS-P, highlight how and when to use codes in this new section.
Coders and CDI specialists often rely on the encoder to determine the MS-DRG. Cheryl Ericson, MS, RN, CCDS, CDIP, reviews the steps necessary to determine the MS-DRG on your own.
Q: I have been asked to build a query for a diagnosis of SIRS and/or sepsis for the following scenario: The patient was admitted for an infection urinary tract infection (UTI), pyelonephritis (PNA) and meets two SIRS criteria. The patient may be treated with oral or intravenous antibiotics, and may be on a general medical floor (not intensive care). The physician did not document SIRS or sepsis. I am having a hard time with this query because I am not sure if this would be considered adding new information to the chart or leading the physician by introducing a new diagnosis. Do you have any suggestions?
A recent salary survey conducted by our sister publication Medical Records Briefing found the same trends prevail year after year: the 145 HIM professionals who responded feel they are overworked and underpaid.
ICD-10-PCS root operations Drainage, Extirpation, and Fragmentation involve removing material from the body, but in different ways. A nita Rapier, RHIT, CCS, Kristi Stanton, RHIT, CCS, CPC, and James Fee, MD, CCS, CCDS, offer tips for distinguishing between the root operations.
The optical system is the most complex organ system of the human body and is subject to specific disease processes. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer explains how to code some common eye diseases and treatments in ICD-10.
CMS announced a new incentive program designed to reduce complications from joint replacement surgery. The new proposed Comprehensive Care for Joint Replacement will require bundling of reimbursement for hip and knee surgeries, with profits tied closely to costs and quality metrics.
Q: Can “in the setting of”' be interpreted as “due to” in ICD-10-CM? For example, the physician documented that the patient has a urinary tract infection in the setting of a urinary catheter.
The AHA’s Coding Clinic for ICD-10 continues to provide updates and guidance for a variety of inpatient procedures, both routine and not so routine. J ames S. Kennedy, MD, CCS, CDIP, Anita Rapier, RHIT, CCS, and Sharme Brodie, RN, CCDS, highlight some important advice from Coding Clinic.
Sharme Brodie, RN, CCDS , highlights guidance on ICD-10-PCS root operations and seventh characters for ICD-10-CM from the latest issue of Coding Clinic .
Coders will find 50 new codes in ICD-10-PCS for 2016, according to the summary of changes posted by CMS . CMS also introduced a new section for ICD-10-PCS, X (new technology). In addition, guidelines B3.11b, B3.4a, B3.2b, and B4.1b were revised in response to public comment.
Q: In ICD-9-CM, sprains and strains fall under the same codes. Will that also be the case in ICD-10-CM or are we going to report these injuries separately?
ICD-10-PCS does not include unspecified options so coders will need information for each of the seventh characters in the code. Cheryl Ericson, MS, RN, CCDS, CDIP, and Lynn Salois, RHIT, CCS, CDIP, review some of the areas where a surgical query might be needed.
Coding Clinic serves as the Supreme Court in interpreting ICD?9?CM or ICD?10?CM/PCS and their guidelines. James S. Kennedy, MD, CCS, CDIP, Kyra Brown, RHIA, CCS, and Nelly Leon-Chisen, RHIA, discuss the best ways to use this additional guidance.
CMS provided plenty of proposed refinements to quality measures in the 2016 IPPS proposed rule, but did not suggest any changes to the 2-midnight rule. Kimberly A.H. Baker, JD, CPC, James S. Kennedy, MD, CCS, CDIP, and Shannon Newell, RHIA, CCS, highlight the most significant proposed changes.
Q: When I started as a coder, I learned that the complication code, such as from ICD-9-CM series 998 or 999, takes precedence as the reason of admission when present with another contributing condition. Is this correct, and is there any written guidance from AHA Coding Clinic for ICD-9-CM/ICD-10-CM/PCS that discusses this?
Shannon Newell, RHIA, CCS, Steve Weichhand, and Sean Johnson conclude their four-part series on PSI 90 with an in-depth look at PSI 12, which evaluates a hospital’s risk adjusted rate of perioperative deep vein thrombosis and/or pulmonary embolism in surgical discharges for patients 18 years and older.
Coding, documentation, and diagnoses aren’t always clear-cut, which can challenge even experienced codes. Review the coding and documentation requirements for encephalopathy, stroke, and anemia.
Coders tell a patient’s story with a principal diagnosis and additional diagnoses, some of which are CCs or MCCs. William E. Haik, MD, FCCP, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, James Fee, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, and Cheryl Ericson, MS, RN, CCDS, CDIP, explain the value of educating physicians and coders about CCs and MCCs.
Q: Should “diabetes with gastroparesis” be coded as 536.3, diabetes with a complication code? I understood that the term ‘"with’" can link two diagnoses, but that it does not represent a cause-and-effect relationship. Can you please clarify this, and why a cause-and-effect relationship can be assumed in the term “diabetes with gastroparesis”?
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Cheryl Ericson, MS, RN, CCDS, CDIP, compare and contrast coding for poisonings and adverse effects in ICD-9-CM and ICD-10-CM and explain the new concept of underdosing.
Patient Safety Indicator 15 tracks events during surgical procedures that can hurt patients, but not whether the patient actually suffers harm from the event. Robert S. Gold, MD, identifies some of the challenges involved with this quality measure.
Coders and clinical documentation improvement specialists need to pay attention to what conditions are considered CCs and MCCs, as well as sequencing rules which could affect MS-DRGs. Laurie L. Prescott, MSN, RN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, and William E. Haik, MD, FCCP, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, discuss some common CCs and MCCs.
As coders have prepared for ICD-10-CM, they have raised questions about how to select the correct seventh character. Nelly Leon-Chisen, RHIA, and Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, offer tips for determining the correct seventh character.
PSI 7 evaluates the hospital’s risk-adjusted rate of central venous catheter-related bloodstream infections. Shannon Newell, RHIA, CCS, Steve Weichhand , and Sean Johnson explain inclusions, exclusions, and risk adjustment factors for this measure.
An automated Recovery Auditor review of discharge status codes identified improper payments, according to the Medicare Quarterly Compliance Newsletter . However, CMS did not report the prevalence of the errors.
Heart failure is the intrinsic inability of the heart to supply target organs with sufficient nutrient flow to function normally. Robert S. Gold, MD, and Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, review the clinical and coding guidelines for heart failure.
PSI 15 measures the hospital’s risk-adjusted rate of accidental punctures and lacerations. Shannon Newell, RHIA, CCS, Steve Weichhand , and Sean Johnson explain inclusions, exclusions, and risk adjustment factors for this measure.
When providers use different definitions for the same disease, confusion and chaos result. Trey La Charité, MD , discusses how coding and clinical documentation improvement specialists can clear up the situation.
Q: A patient came to the ED with shortness of breath (SOB). The admitting diagnosis was possible acute coronary syndrome (ACS) due to SOB and elevated troponin levels. The ACS was ruled out. Elevated troponin levels were assumed to be due to chronic renal failure (CRF), and no reason was given for SOB. Before discharge, the patient was noted with an elevated temperature and found to have a urinary tract infection (UTI). All treatment was directed at the UTI, and the doctor noted the discharge diagnosis as the UTI. What would be the principal diagnosis in this case?
The 2014 ICD-10 implementation delay negatively impacted ICD-10 preparations, according to the Workgroup for Electronic Data Interchange (WEDI) February 2015 readiness survey .
The seventh character in an ICD-10-CM code represents either the fetus (for pregnancy codes), or the encounter (for injuries and burns). Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, Gretchen Young-Charles, RHIA, and Nelly Leon-Chisen, RHIA, review guidelines for correct seventh character selection.
In ICD-10-CM, coders will use a seventh character, not an aftercare code, to identify follow-up treatment for an injury. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-DAM, Kristi Pollard, RHIT, CCS, CPC, CIRCC, and Anita Rapier, RHIT, CCS, explain how aftercare coding will change in ICD-10-CM.
Percutaneous transluminal coronary angioplasty (PTCA) is a minimally invasive procedure to open up blocked coronary arteries. Laura Legg, RHIT, CCS, AHIMA-approved ICD-10-CM/PCS trainer, Mary H. Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, and Sara Clark, RHIA, MLS, AHIMA-approved ICD-10-CM/PCS trainer, explain how coders will report PTCA in ICD-10-PCS.
A complication basically refers to an unexpected result, outcome, or event. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Cheryl Ericson, MS, RN, CCDS, CDIP, and Trey La Charité, MD , detail when to report a complication and highlight the differences in complication coding between ICD-9-CM and ICD-10-CM.
CMS Transmittal 3217 , effective April 1, will allow inpatient-only procedures to be included on inpatient claims, similar to other outpatient services included in the three-day window.
The physician documented “encephalopathy” in the progress note of a patient who was admitted with a cerebrovascular accident (CVA) and/or possible seizures. James S. Kennedy , MD, CCS, CDIP, discusses what to consider when determining whether to code the encephalopathy.
Myths and misinformation about query practices still remain. Cheryl Ericson, MS, RN, CCDS, William E. Haik, MD, FCCP, CDIP, CDIP, and Nelly Leon-Chisen, RHIA, provide a refresher on how and when to query physicians.
Q: How should the diagnosis of urinary tract infection (UTI) and encephalopathy be sequenced, specifically which diagnosis should be the principal? If physician documentation indicates that the patient came in with confusion, can encephalopathy be assigned as the principal diagnosis if it is due to the UTI and no other contributing issues are present?
Clinical documentation improvement (CDI) specialists must understand CMS pay-for-performance measures in order to improve data quality . Shannon Newell, RHIA, CCC, AHIMA-approved ICD-10-CM/PCS trainer, Steve Weichhand, and Sean Johnson explain how Patient Safety Indicator 90 is measured and what role CDI specialists play in capturing data for this measure.