Q: When querying a physician to confirm the stage of a pressure ulcer, is it appropriate to ask questions that require the physician to mark “yes” or “no” responses to the query?
Allen Frady, RN-BSN, CCDS, CCS, CRC, explains the value of tracking and understanding key performance indicators (KPI), and gives advice on how facilities can improve on its practices.
The cost for a hospital stay in 2014 involving acute renal failure (ARF) averaged $19,200, nearly twice the $9,900 average cost for stays not involving renal failure, according to the statistical brief published by The Healthcare Cost and Utilization Project (HCUP).
James S. Kennedy, MD, CCS, CCDS, CDIP, writes about potential coding compliance issues raised in the Office of Inspector General’s (OIG) Work Plan for providers to consider, including documentation and coding for severe malnutrition and bariatric surgery.
Q: If a patient is admitted with a high blood alcohol level and the provider documents the blood alcohol level in his or her note, does the provider also need to specifically write “patient with intoxication?”
Medical necessity denials are commonly encountered in facilities. Complete understanding and utilization of the ICD-10-CM/PCS coding guidelines is imperative for coders and coding mangers to recognize how to avoid these denials. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Hospitals reduced central line-associated bloodstream infections (CLABSI) by 50% between 2008 and 2016, according to a new report released by the Centers for Disease Control and Prevention (CDC).
Because Hierarchical Condition Categories (HCC) and similar risk-adjustment methodologies impact physician and hospital practices, James S. Kennedy, MD, CCS, CDIP, CCDS , reviews CMS’ Risk-Adjustment Data Validators (RADV) instructions to improve HCC compliance.
According to the American Cancer Society, in 2017 there were an estimated 1,688,780 new cancer cases diagnosed and 600,920 cancer deaths in the U.S. In this article, Peggy Blue, MPH, CCS, CCS-P, CPC, CEMC , breaks down the usage of the ICD-10-CM neoplasm table and reviews coding for neoplasm admissions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: According to the ICD-10-CM Official Guidelines for Coding and Reporting, uncertain diagnoses should be documented at the time of discharge. If a consultant documents an uncertain diagnosis in the final or last progress note and not in the discharge summary, can we code that uncertain diagnosis?
Emergency departments at designated trauma centers encounter some of the most complex patients—and with them, a complicated documentation web that’s difficult to untangle, making trauma case review essential for hospitals.
James S. Kennedy, MD, CCS, CDIP, CCDS, reviews some ICD fundamentals and to help facilities develop a strategy that will ease the transition to the new administrative language as the federal government moves toward deployment of the International Classification of Diseases, 11th Edition, for Mortality and Morbidity Statistics (ICD-11-MMS).
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, writes that since there is such a prevalence for obesity in our nation, it’s a no brainer that correctly assigning and fully understanding the ICD-10-CM/PCS codes for obesity-related conditions is imperative for coders in any facility.
Q: We keep receiving denials for our use of ICD-10-CM code G94 (other disorders of brain in diseases classified elsewhere). Is there any coding guidance out there that can help our coding team decipher when we can use this code?
Creating a query and knowing when to query can be complicated, and there are a number of training tactics that can prove successful for coders when trying to improve upon physician query practices. For this article, let’s take a look at when coders should query and when it’s appropriate for them to cite clinical evidence. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Only 12% of eligible hospitals signed up for CMS’ Bundled Payments for Care Improvement Model 2 initiative and 47% of them dropped out completely within two years, according to a recent study by the Journal of the American Medical Association .
Surprisingly, thyroid disease is more common than diabetes or heart disease, with an estimated 20 million Americans having some form of the disease. In this article, Yvette M. DeVay, MHA, CPC, CPMA, CIC, CPC-I gives readers a background on thyroid cancer and reviews ICD-10-CM/PCS coding for the disease.
On January 9, CMS announced the launch of Bundled Payments for Care Improvement Advanced from the agency’s Center for Medicare and Medicaid Innovation.
Q: If the attending physician documented, “likely mixed cardiogenic and septic shock,” can I assign ICD-10-CM codes R57.0 (cardiogenic shock) and R65.21 (severe sepsis with septic shock)?
Lynelle A. Clausen, RN, BSN, writes about the struggles she faces as a CDI specialist when dealing with vague documentation, lack of criteria, and the reporting of malnutrition.
