CMS focused on quality measures in the 2015 IPPS proposed rule, released April 30. Kimberly A.H. Baker, JD, Cheryl Ericson, MS, RN, CCDS, CDIP, James S. Kennedy, MD, CCS, CDIP ,and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, highlight the most significant proposed changes.
For anyone who has not yet started ICD-10 training, CMS posted a transcript, audio file, and slide presentation from the June 4 More ICD-10 Basics MLN Provider call on its website.
Sequela, or late effect, is the remaining or lasting condition produced after the acute stage of a condition or injury has ended. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, reviews the correct way to code for sequelae in ICD-9-CM and ICD-10-CM.
Learning to code in ICD-10-PCS is in some respects like learning a language, you need a strong foundation in the rules. Sue Bowman, MJ, RHIA, CCS, FAHIMA , Gerri Walk, CCS-P , Nena Scott, MSEd, RHIA, CCS, CCS-P , and Jennifer Avery, CCS, CPC-H, CPC, CPC-I, discuss the guidelines related to root operations in ICD-10-PCS.
Both knee and shoulder replacement procedures include devices and fall under the ICD-10-PCS root operation Replacement (R). Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, and Nena Scott, MSEd, RHIA, CCS, CCS-P , review the definition of a device in ICD-10-PCS and review how to code for shoulder and knee replacements.
ICD-10-PCS root operations Occlusion, Restriction, and Dilation involve changing the diameter of a tubular body part. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Angie Comfort, RHIT, CDIP, CCS, review the definitions of these root operations and examine when they should be used.
Both knee and shoulder replacement procedures include devices and fall under the ICD-10-PCS root operation Replacement (R). Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, and Nena Scott, MSEd, RHIA, CCS, CCS-P , review the definition of a device in ICD-10-PCS and review how to code for shoulder and knee replacements.
Some conditions, such as gangrene due to diabetes, require two codes to correctly report in ICD-9-CM. In ICD-10-CM, coders will only need one code. Jennifer Avery, CCS, CPC-H, CPC, CPC-I, and William E. Haik, MD, FCCP, CDIP, explain how these combination codes act as their own CC or MCC in ICD-10-CM.
Reporting codes for use, abuse, and dependence isn’t completely new for ICD-10-CM. Coders can report them in ICD-9-CM. Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, reviews the meaning of use, abuse, and dependence and how to code these conditions.
Q: We had a question regarding documentation in a record of SIRS due to acute peritonitis without sepsis. Our critical care physician on that case called it severe sepsis as well. What would you do in a situation like that?
Coders can only use the documentation they have to code in ICD-9-CM and ICD-10-CM. Adelaide La Rosa, RN, BSN, CCDS, and Deborah Lantz, RHIA, discuss the importance of good documentation when coding for fractures and congestive heart failure in both systems.
Pneumonia is an inflammatory process that affects the lung tissue. Robert S. Gold, MD , and Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, explain the clinical and documentation pieces of pneumonia coding.
Q: I’m in a little debate: Does documentation of the patient’s body mass index (BMI) need to come from an ancillary clinician, like the dietitian or nurse? I thought that we could use such ancillary documentation for clinical indicators supporting our physician query, but the treating physician needed to document the BMI. Can you help clarify this for me?
CMS’ 2015 IPPS proposed rule , released April 30, focuses on quality measures, such as the hospital-acquired condition (HAC) reduction, readmissions reduction, and hospital value-based purchasing and hospital readmissions reduction programs.
Four ICD-10-PCS root operations involve procedures that put in, put back, or move some or all of a body part. Gerri Walk, RHIA, CCS, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, highlight the differences among Reattachment, Reposition, Transfer, and Transplantation.
Cheryl Ericson, MS, RN, CCDS, CDIP, discusses the difference between “after study” and “due to” when it comes to choosing the correct principal diagnosis .