Heather Taillon, RHIA, Cheryl Collins, BS, RN , and Andrea Clark, RHIA, CCS, CPC-H , explain the basic rules regarding principal diagnosis selection in general and for neoplasms in particular in ICD-9-CM.
Coders may need to have a conversation with physicians about how changes in ICD-10-CM could require additional documentation for mental disorders due to a known physiological condition. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, compares coding for these conditions in ICD-9-CM and ICD-10-CM.
The World Health Organization (WHO) is delaying the launch of ICD-11 until 2017. The WHO did not formally announce a delay, but its website now lists ICD-11 as due by 2017.
ICD-10-PCS defines devices for coding purposes in a very specific way. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, explain how to assign the correct device character in ICD-10-PCS.
Inpatient coders will have a new coding system on October 1, but they won’t have to learn new MS-DRGs. They aren’t changing. However, coders will see some shift in MS-DRG assignment in ICD-10. Donna M. Smith, RHIA, and Lori P. Jayne, RHIA, reveal why the MS-DRG shifts will occur.
Q: Does the physician have to document the stage of a decubitus ulcer or can it be a wound care nurse? Does that person have to document stage 1 or can he or she describe the wound?
Decreased productivity isn’t the only looming concern with the transition to ICD-10. Scot Nemchik, CCS , and Rachel Chebeleu, MBA, RHIA , reveal why accuracy will be just as important as productivity.
Physicians can biopsy numerous body sites and structures, including muscles, organs, and fluids. Mark N. Dominesey, MBA, RN, CCDS, CDIP, and Nena Scott, MSEd, RHIA, CCS, CCS-P, dig into biopsy coding in both ICD-9-CM and ICD-10-CM.
Codes for epilepsy and migraine headaches are getting a makeover for ICD-10-CM. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, reviews the additional specificity in the new ICD-10-CM codes.
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.
Q: Can you explain when a neoplasm should be listed as the principal diagnosis? We have some coders who believe the neoplasm should always be the principal diagnosis.
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.
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 .
Drug-resistant bugs are becoming more common as antibiotic use increases. Shelley C. Safian, PhD, CPC-H, CPC-I, CCS-P , AHIMA-approved ICD-10-CM/PCS trainer, explains why and how microbes become antibiotic resistant and compares ICD-9-CM and ICD-10-CM coding for these infections.
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.
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?