ICD-10-PCS root operations Control and Repair are used when a procedure doesn’t really fit into a different root operation. Nena Scott, MSEd, RHIA, CCS, CCS-P, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS , discuss when coders should use these two root operations.
The 2015 IPPS final rule focused on quality measures. James S. Kennedy, MD, CCS, CDIP, and Cheryl Ericson, MS, RN, CCDS, CDI-P, highlight the changes and explain the role of coding in quality scores.
In part 2 of his series on medical necessity and coding, Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, examines medical necessity and the 2-midnight rule using a case study.
Heart failure is one of the top MS-DRGs, so Recovery Auditors have focused on identifying potential coding problems with MS-DRGs 291, 292, and 293. Recovery Auditors identified errors related to sequencing of the principal diagnosis and improper coding of secondary diagnoses, according to the Medicare Quarterly Compliance Newsletter .
CMS proposed a major change to physician certification requirements in the 2015 OPPS proposed rule. Kimberly A.H. Baker, JD and James S. Kennedy, MD, CCS, CDIP, break down how the change could affect inpatient admissions.
Q: How would the following be viewed if it was included in a cardiology consult note: Mr. Jones has paroxysmal atrial fibrillation. He had a recurrence last night which was asymptomatic. We think this happens all the time at home. This is not a pacing post-conditioning (PPC). He is back in normal sinus rhythm (NSR). I would restart his warfarin if Dr. Smith will allow. Goal International Normalized Ratio (INR) is 2-3.
The Official ICD-9-CM Guidelines for Coding and Reporting talk about the perinatal and newborn period as being the first 28 days of life. Robert S. Gold, MD, explains when neonatal really is—and isn’t—neonatal.
Spinal fusion is a procedure to join, or fuse, two or more vertebrae and can be performed in both the inpatient and outpatient settings. Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, MCP, review spinal anatomy before discussing correct ICD-9-CM Vol. 3 and ICD-10-PCS coding for inpatient spinal fusions.
The section of codes that expanded most in ICD-10-CM involves orthopedic injuries, especially fractures. Kim Carr, RHIT, CCS, CDIP, CCDS , and Kristi Stanton, RHIT, CCS, CPC, CIRCC, highlight some of the most significant changes for fracture coding.
Q: ICD-9-CM includes Pott’s fracture as an alternate term for a bimalleolar fracture. However, ICD-10-CM doesn’t include that term in either the Alphabetic Index or the Tabular List. If the physician documents a Pott’s fracture, can we automatically use the code for bimalleolar fractures in ICD-10-CM, even though the term is not in the index?
When a patient comes in contact with a drug or chemical that has an unhealthy effect, coders will have an easier time reporting it in ICD-10-CM than in ICD-9-CM. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer reviews poisoning and adverse effect coding in both code sets.
The 2015 IPPS final rule , released August 4, focuses on quality initiatives and includes no ICD-9-CM diagnosis or procedure code changes. However, CMS did finalize some MS-DRG changes for Fiscal Year 2015.
ICD-10-PCS includes three root operations that involve taking out or eliminating solid matter, fluids, or gases from a body part. Donna Smith, RHIA, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, review root operations Drainage, Extirpation, and Fragmentation.
Coders use different codes to report traumatic and pathologic fractures. Robert S. Gold, MD, and Kristi Stanton, RHIT, CCS, CPC, CIRCC, highlight the differences in coding for the two etiologies of fractures in both ICD-9-CM and ICD-10-CM.
Physician documentation drives quality measures, but physicians often don’t understand the link between the two. James Fee, MD, CCS, CCDS, Kristi Stanton, RHIT, CCS, CPC, CIRCC, and Jane Bonewell, RHIT, offer suggestions for ways to educate providers and improve documentation.
Improper ICD-9-CM code assignment led to incorrect grouping of claims to MS-DRG 857 (postoperative or posttraumatic infections with operating room procedure with complications and comorbidities), according to Recovery Auditors. CMS released the findings in the July 2014 Medicare Quarterly Provider Compliance Newsletter .
Coders now incorporate consideration of medical necessity when coding for inpatient admissions. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI , explains the importance of understanding the concept of medical necessity as it relates to coding.
Q: We know that we can look at the radiology report to get some specifics about a fracture. When it comes to an open fracture in ICD-10-CM, can you determine the Gustilo-Anderson classification, whether it's I, II, IIIA, IIIB, or IIIC, based on a description of the wound? Or does the physician actually have to document, “It's a Gustilo type I" or "type III”?
The complexity of coding rules and the quality of documentation in facilities sometimes make correct DRG assignment a daunting task. Laura Legg, RHIT, CCS, highlights current DRGs that are subject to Recovery Auditor scrutiny and provides tips for accurate DRG assignment.
