Without the right details in the documentation, coders can’t assign the correct code and that becomes more apparent in ICD-10. Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, Paul Weygandt, MD, JD, MPH, MBA, CCS , Kathy DeVault, RHIA, CCS, CCS-P, and Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, highlight some areas coders and clinical documentation improvement specialists should focus on to prepare for ICD-10.
Coders are often in the difficult position of trying to determine whether to report a CC. William E. Haik, MD, FCCP, CDIP, and Kathy DeVault, RHIA, CCS, CCS-P, discuss problems areas in documentation of CCs and what clinical indicators coders should use to help with CC reporting.
Recovery Auditors have identified substantial overpayments for inpatient psychiatric services directly following an acute care stay within the same facility, according to CMS’ MLN Matters® SE1401 .
Information that is not important for ICD-9-CM will take on new significance in ICD-10-CM. Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, and Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, review areas when specificity comes into play in ICD-10-CM.
In ICD-10-PCS, coders will need to find details they currently don’t use. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, offers tips for locating the necessary information in the body of the operative report.
Q: In ICD-10-PCS, which root operation would we report for an obstetrical delivery? Would it change for a cesarean section versus a manually assisted vaginal delivery?
ICD-10-PCS implementation is less than a year away, so the pressure is on coders to learn the new system and maintain productivity. Gerri Walk, RHIA, CCS-P, AHIMA-approved ICD-10-CM/PCS trainer, discusses how to overcome some of the challenges inpatient coders will face in ICD-10-PCS.
CMS released version 31 of the MS-DRG grouper for ICD-10 in November. Providers can use the grouper to identify MS-DRG shifts and payment changes under ICD-10. The Final ICD-10 MS-DRG v32 logic, which will be implemented on October 1, 2014, will be subject to rulema
Documentation and medical necessity continue to be scrutinized by payers and auditors. Debbie Mackaman, RHIA, CPCO, and Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, explain how complete, accurate documentation of the entire patient encounter justifies the physician’s decision to admit.
Problems can occur anywhere along the alimentary canal or in any of the accessory organs. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, discusses some common diagnosis and procedure codes for digestive diseases and procedures.
The audit landscape continues to change as Recovery Auditors expand prepayment reviews and CMS implements its new 2-midnight rule. Debbie Mackaman, RHIA, CPCO, Ralph Wuebker, MD, MBA, and Kimberly Hoy Baker, JD, review some of the recent changes to audit focus areas.
Q: Can you ask a yes or no question in a query based on clinical information from a previous echocardiogram report or other diagnostic result from a previous admission?
CMS created a 2-midnight presumption and benchmark as part of the 2014 IPPS Final Rule as a way to clarify its guidelines for inpatient admission. However, the American Hospital Association (AHA) and American Medical Association (AMA) believe the clarification creates more confusion.
Q: What recommendation would you give to the coder when the clinical indicators in the chart do not support sepsis but it’s in the final diagnostic statement?
When an error occurs in coding, sometimes the coders miscodes a record, but in others, the documentation is deficient, leading to incorrect code assignment. Joy Strong, PMP, Donielle Bailey, RHIA, and Jill M. Young, CPC, CEDC, CIMC, discuss how good documentation and accurate coding go hand in hand.
Coders may find assigning codes for sepsis somewhat easier in ICD-10-CM, but they will still face some challenges. Ann Barta, MSA, RHIA, CDIP , and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CCDS, detail how to report sepsis in ICD-10-CM.
Some hospitals are incorrectly reporting lymphoma and leukemia MS-DRGs for patients who are admitted and treated for anemia and dehydration, according to the Medicare Quarterly Provider Compliance Newsletter .
Clinical queries serve a definitive purpose when documentation in the medical record is ambiguous, inconsistent, lacking specificity, or contradictory. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, explains why documentation improvement initiatives and heightened coder awareness of the need to query can be an asset or liability.
Physicians believe they are providing quality care, which gives them high job satisfaction. However, the problems associated with using electronic health records decreased that satisfaction, according to a recent RAND survey.
The ICD-10 implementation will result in a slowdown at every level of coding. Elaine O’Bleness, MBA, RHIA, CHP, Migdalia Hernandez, RHIT, Kimberly Carr, RHIT, CCS, CDIP, and Rachel Chebeleu, MBA, RHIA, provide suggestions on how to minimize that productivity decline.
Recovery Auditors are data mining for sepsis MS-DRGs and then focusing in on those with a short length of stay. Robert S. Gold, MD, and Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, provide tips for correct sepsis coding to avoid auditor takebacks.
A wound is an injury to living tissue caused by a cut, blow, or other external or internal factor. Robert S. Gold, MD , and Gloria Miller, CPC, CPMA , review anatomy and documentation for wounds and explain how to code for wound care in ICD-9 and ICD-10.
The ICD-10-PCS Official Guidelines for Coding and Reporting address four specific circumstances when coders will report multiple procedures. Jennifer Avery, CCS, CPC-H, CPC, CPC-I, and Mark N. Dominesey, MBA, RN, CCDS, CDIP, HIT Pro-CP, explain the guidelines and how they differ from the current ICD-9-CM guidelines.
Approach is the fifth character in the ICD-10-PCS code. Laura Legg, RHIT, CCS, AHIMA-approved ICD-10 CM/PCS trainer , reviews the seven approaches used in ICD-10-PCS.
Coders will use an ICD-10-PCS table to build a code for a hip or knee replacement. As with any procedure, coders must first determine the root operation. Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CPMA, CEMC, CPCD, COBGC, CCS-P, CDIP, and Wanda L. Cidor, guide you through coding for these procedures.
Physicians often use different terms interchangeably when documenting sepsis. Robert Gold, MD , and Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, define the different terms and review when to query for additional clarification.
CDI specialists shouldn’t focus on reimbursement, yet the reality is that improved documentation often does lead to higher payments for the hospital. Darice Grzybowski, MA, RHIA, FAHIMA, and Jon Elion, MD, offer tips on how CDI programs can mitigate ethical quandaries and demonstrate best practice.
Although ICD-10-CM resolves some problematic areas of coding, it isn't a panacea. Robert S. Gold, MD reviews how respiratory insufficiency will continue to challenge coders.
In order for coders to report ICD-9-CM procedure code 96.72 (continuous invasive mechanical ventilation for 96 consecutive hours or more), the provider must document that the patient received more than 96 hours of continuous ventilation. A recent OIG report found that 96% of claims incorrectly included code 96.72 between 2009 and 2011.
Acute kidney injury (AKI) is an abrupt decrease in kidney function that includes—but is not limited to—acute renal failure. Garry L. Huff, MD, CCS, CCDS , and Brandy Kline, RHIA, CCS, CCS-P, CCDS , explain the clinical indicators of AKI and offers tips for composing queries.
ICD-10-CM and ICD-10-PCS present different challenges, but both will require better documentation. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Kathy DeVault, RHIA, CCS, CCS-P, Donielle Bailey , and Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, discuss some of the areas where coders will need more information to code in ICD-10.
The best way to decrease denials or increase overturn rates begins with a compliant concurrent review of documentation. Marilyn S. Palmer, DO, and Jonathan G. Wiik, MSHA, MBA, review common Recovery Audit targets and provide tips for successfully appealing denials.
Hospitals are being incorrectly reimbursed for preadmission testing that occurs within the three days prior to admission, according to Recovery Audit findings.
Q: A patient presents with altered mental status/encephalopathy due to a urinary tract infection (UTI). The patient has a history of dementia. The final diagnosis is encephalopathy due to UTI. Should we code the encephalopathy as a secondary diagnosis because it’s an MCC and not always a symptom of a UTI?
No one is perfect, including coders. Mistakes aren’t necessarily a reflection on one’s abilities or attention to detail. James S. Kennedy, MD, CCS, and Laura Legg, RHIT, CCS, highlight some common problem areas and provide tips for compliance.
The 2014 IPPS Final Rule contains two significant changes that will impact coders: the 2-midnight inpatient presumption and the Part A to Part B rebilling. Marc Tucker, DO, FACOS, FAPWCA, MBA, and Kimberly Anderwood Hoy Baker, JD, CPC, review the key provisions of these changes.
Q: A patient undergoes placement of a MediPort ® to receive chemotherapy for lung cancer. What principal diagnosis should we report? Should we report V58.81 (fitting and adjustment of vascular catheter) or 162.9 (malignant neoplasm of bronchus and lung unspecified)?
Unlike ICD-10-CM, ICD-10-PCS does not include unspecified codes. Thus, clinicians may see an increased number of queries on procedures post-implementation. Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, explains why facilities should review documentation for inpatient procedures now.
Health information exchange between hospitals and other providers has risen by 41% between 2008 and 2012, according to research published in Health Affairs from the Office of the National Coordinator for Health Information Technology (ONC).
Does the DRG accurately depict the patient’s story? Does the length of stay and severity of illness correlate with what actually happened? Heather Taillon, RHIA, and Cheryl Collins, BS, RN, offer tips to selecting the correct principal diagnosis.
Q: Our facility has a question about how other hospitals address this scenario: Patient is discharged to home (discharge status code 01). No documentation exists in the medical record to support post-acute care. Several months later, our Medicare Administrative Contractor (MAC) notifies us that the patient indeed went to post-acute care after discharge. The MAC retracts our entire payment. We need to resubmit the claim with the correct discharge status code. We are reluctant to do so because nothing in the medical record supports the post-acute care provided. Are other hospitals amending the record? If so, which department is adding the amended note?
Diagnostic conclusion statements don’t sufficiently capture the clinical context and medical necessity for inpatient admission. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, discusses the importance of clinical context and quality of clinical documentation in the medical record.
The 2014 draft ICD-10-PCS guidelines include a code for the usage of a robotic-assist device in surgery, something coders can currently report in ICD-9-CM. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , compares documentation requirements for coding robotic-assisted surgery in both ICD-9-CM and ICD-10-PCS.
At first glance, codes for insertion, removal, and revision of pacemakers look quite different in ICD-10-PCS. Kimberly J. Carr, RHIT, CCS, CDIP, and Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, compare and contrast pacemaker procedure coding in ICD-9-CM and ICD-10-PCS.
Complete capture of procedure codes in ICD-9-CM helps to ensure accurate translation to ICD-10-PCS. Donna M. Smith and Patricia L. Belluomini, RHIA, reveal coding errors—including omission of procedure codes—that make the translation process more challenging.
