ICD-9-CM and ICD-10-CM differentiate between acute and chronic meniscus tears. Kristi Pollard, RHIT, CCS, CPC, CIRCC , and Gretchen Young-Charles, RHIA, review how to code these injuries in both systems.
Three university hospitals saw a doubling of Recovery Auditor audit activity from 2010–2011 to 2012–2013, and a nearly three-fold increase in overpayment determinations, according to a new study in the Journal of Hospital Medicine.
Q: Can CDI programs use the information on ambulance forms or trip tickets to abstract from if the information is pulled into or reiterated in the ED or history and physical (H&P) documentation? Our staff doesn’t want to miss criteria that would diminish our ability to substantiate the true severity of illness of some patients, but I have been informed that coders are not allowed to code from ambulance papers or information.
Coders and clinical documentation improvement specialists often focus on different information when reviewing documentation for heart disease. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Cheryl Ericson, MS, RN, CCDS, CDIP, highlight the different perspectives.
Coders and clinical documentation specialists can use queries to improve physician documentation of a patient’s severity of illness and risk of mortality. Rhonda Peppers, RN, BS, CCDS, and Sara Baine, MSN-Ed, CCDS, walk through a case study to highlight query opportunities.
Q: A patient comes in with a malunion of a fracture. A different physician treated the patient initially for the fracture, but the patient came to see our physician for surgery to repair the malunion. Which seventh character should we use: A for initial encounter or P for subsequent encounter for fracture with malunion?
CMS is adequately preparing to implement ICD-10 October 1, according to a new Government Accountability Office (GAO) report detailing CMS’ transition efforts.
The ICD-10-PCS Manual includes 17 different sections, including Administration. Learn how to assign codes from this section to prepare for ICD-10-PCS implementation.
Coronary artery bypass graft procedures are not the only ones coders will report using the root operation Bypass in ICD-10-PCS. Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, and Lisa Crow, MBA, RHIA, explain how to code for other bypass procedures in ICD-10-PCS.
A hiatus from Recovery Auditor scrutiny may have allowed HIM professionals to focus on other issues, but Laura Legg, RHIT, CCS, explores why HIM departments need to gear up for Recovery Auditors’ return.
Q: When atelectasis is noted on an ancillary test such as a CT scan of the abdomen or chest x-ray, can nursing documentation of turning, coughing, and deep breathing be considered an intervention that qualifies as one of the criteria to meet a secondary diagnosis?
In order to identify patients with a CC or MCC, coders need to know when to report additional diagnoses. William E. Haik, MD, FCCP, CDIP, and Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, discuss when to report a secondary diagnosis.
Accurately painting a picture of the patient's severity of illness (SOI) and risk of mortality (ROM) is essential for good patient care, and it is becoming increasingly important for quality measures and reimbursement. Sara Baine, MSN-Ed, CCDS, and Rhonda Peppers, RN, BS, CCDS , explain the importance of accurately reporting conditions that affect SOI and ROM.
Physician documentation for the use of osteogenic stimulators for nonunion of fractures is often insufficient for Medicare coverage, according to Comprehensive Error Rate Testing (CERT) results .
Auditors continue to scrutinize inpatient wound care services. Glenn Krauss,BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, reviews the importance of documenting medical necessity for these services.
The District of Columbia federal district court dismissed a lawsuit December 18, 2014, filed by the American Hospital Association (AHA) against HHS for excessive and inappropriate Recovery Auditor denials, according to AHA News. The AHA announced that it may appeal the court’s decision.
