Providers will continue to use the same definition of inpatient status that they already know. That’s because despite CMS’ consideration of various provider comments, the agency has not establish new criteria.
Q: As a traveling consultant, I review many types of inpatient hospital records. As hospitals have implemented electronic health records (EHR), I’ve seen documentation worsen. The ability to cut and paste information in the record has compromised coding accuracy. It has also increased the volume of queries, which frustrates physicians. For example, a physician performs a history and physical (H&P) in his or her office one week prior to admitting a patient to the hospital. The first progress note in the EHR—as well as each subsequent progress note—includes the exact same documentation. This documentation, which continues for four days while the patient is in the hospital, is clearly based on the original H&P. Obviously, the documentation has been copied and pasted from one note to another. Even the patient’s vital signs remain exactly the same as they were in the physician’s office. Coders have no way of knowing whether physicians who treat the patient in the hospital agree with any test findings because residents simply cut and paste the results in each subsequent progress note. Residents claim that they do this solely for the attending physician’s convenience. Clinical documentation improvement (CDI) specialists don’t address the problem because they are more focused on determining the accuracy of the MS-DRG. Is there a solution that will keep physicians, coders, and CDI specialists all on the same page?
Q: Should we query for the specific pulmonary exacerbation of cystic fibrosis (CF)? Coding Clinic states that the exacerbation of CF should be listed first.
Hospitals are overturning Recovery Auditor denials nearly 75% of the time, according to recent RACTrac data. That’s why the American Hospital Association adamantly supports a new proposed bill—the Medicare Audit Improvement Act of 2012 —aimed at holding Recovery Auditors accountable for inappropriate denials.
Every few years, the AHA publishes guidance in Coding Clinic that can significantly affect inpatient coders, such as guidance published in the Second Quarter 2012 on neoplasm coding. Randy Wagner, BSN, RN, CCS, and Paul Dickson, MD, CCS, CPC, review the new guidance and how to use the TNM cancer staging system.
So many coding topics to audit, yet so few staff members to perform those audits. Julie Daube, BS, RHIT, CCS, CCS-P, reveals steps you can take to resolve this dilemma and determine which areas to audit in 2013.
Maternal fetal medicine procedures highlight the differences between ICD-9-CM procedure codes and ICD-10-PCS codes and can serve as a foundation for understanding ICD-10-PCS. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, demonstrates how coding for fetal thoracentesis will change after the switch to ICD-10.
Thinking about exiting the coding profession before the transition to ICD-10? Laura Legg, RHIT, CCS, enjoys coding too much to give it up and offers some tips for how to prepare for the transition.
Although hospital infection rates continue to decline, Medicare payment penalties are not the cause, according to the New England Journal of Medicine article titled Effect of Nonpayment for Preventable Infections in U.S. Hospitals .
Ethical dilemmas can creep in at any time during a coder’s average workday. However, one might be hard pressed to find a coder who will openly acknowledge this. Brad Hart, MBA, MS, CMPE, CPC, COBGC, and Kathy DeVault, RHIA, CCS, CCS-P, explore how coders can and should handle ethical dilemmas.
Coders can go a bit overboard when reporting CCs and MCCs. Cheryl Ericson, MS, RN, CCDS, CDIP, and Deborah K. Hale, CCS, CCDS, reveal the dangers of over-reporting CCs and MCCs and how to report them appropriately.
CMS has published two ICD-10-related Special Edition Medlearn Matters articles that may be of interest to providers and serve as tools to assist with implementation.
Assess. Educate/train. Practice. Gloryanne Bryant, RHIA, CCS, CDIP, CCDS, and Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CPMA, CEMC, CPCD, COBGC, CCS-P CDIP, reveal how following those three steps can prepare you for ICD-10 implementation.
In ICD-9-CM, coders report specific codes to indicate a surgeon used robotic assistance. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, explains how that will change in ICD-10-PCS.
ICD-10-CM code category J45.- includes new, more specific terms for asthma that may help improve data quality and lead to more effective research and treatments. Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CPMA, CEMC, CPCD, COBGC, CCS-P CDIP, and Suzan Berman, CPC, CEMC, CEDC, detail the new terminology for asthma coding in ICD-10-CM.
Q: I have a question about coding transplant complications. My understanding is if the complication affects the transplanted organ, then coders should assign a code for the transplant complication itself. Is this correct? Consider the following physician documentation: Final A/P: Acute renal failure in patient with history of renal transplant. Should coders report 996.81 (complications of transplanted kidney) and 584.9 (acute kidney failure, unspecified)? Also consider this documentation: CHF in heart transplant patient . Should coders report 996.83 (complications of transplanted heart) and 428.0 (CHF, unspecified)?
The HIM profession is constantly changing, but HIM professionals are still responsible for maintaining the integrity of the health records. Lou Ann Wiedemann, MS, RHIA, FAHIMA, CPEHR, explains why HIM professionals can—and should—also play a role in clinical documentation improvement (CDI).
Provider documentation of inpatient wound care services may be confusing at best and completely lacking at worst. Coders end up trying to decipher exactly what procedure the provider performed. Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, and Robert S. Gold, MD, offer tips to assist coders in choosing the correct code for inpatient wound care.
