Medical necessity is the foundation for justifying the need for services. It provides the reason for the diagnostic test or therapeutic services. Anna Santoro, MBA, CCS, CCS-P, RCC, CHRI , reviews the fundamentals of medical necessity and explains its importance.
A recent ProPublica article found that nearly 30,000 Medicare patients may have received atherectomy procedures prematurely or unnecessarily, resulting in millions of dollars in reimbursement.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a broad federal law that establishes the basic privacy and security protections that coders are required to follow.
The 2024 ICD-10-CM update added 36 codes to the now nearly 400 codes in category M80.- (osteoporosis with current pathological fracture). The additional codes add further specificity for pelvis fractures due to age-related osteoporosis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Julia Kyles, CPC , contrasts 2024 CPT guidance and CMS’ 2024 Medicare Physician Fee Schedule (MPFS) final rule for changes to office visits, prolonged services, and split/shared services.
Q: A patient underwent a diagnostic nasal endoscopy at 10 a.m. At 7 p.m., the patient developed an epistaxis and the physician had to use some complex cauterizing techniques to control the nosebleed. How would the physician’s services in this scenario be reported?
The National Correct Coding Initiative released the 2024 NCCI Policy Manual in early December, which will be effective January 1. This article covers the changes—both big and small. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS released its January 2024 HCPCS Level II code update December 7, outlining 344 new and 74 discontinued codes. The code changes will become effective January 1, 2024.
Traversing the different rules within cardiac and interventional radiology reporting is a challenge. Alysia Minott, CCS, CIRCC, CDIP , explains anatomic and documentation details coding professionals need to know to report these procedures.
Anemia describes a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient. Review the types of anemia, diagnostic criteria, treatment, and ICD-10-CM coding. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Spinal surgery for hospital coders can be very challenging if they do not know the rules for assigning the correct ICD-10-PCS codes. Nancy Reading, RN, CPC, CPC-P , reviews spinal anatomy and surgical approaches, and offers tips on how to select the most appropriate characters in ICD-10-PCS.
U.S. government civil healthcare fraud settlements exceeded $1.6 billion in 2022, according to the recently released 2022 Health Care Fraud and Abuse Control Program Annual Report.
The healthcare setting can feel like a courtroom in the denials and appeals arena. By assessing the effort that goes into an appeal and the difference that comes out of them, coders and CDI specialists may find that the chasm between clarifying a patient record and defending it isn’t as wide as they think.
Our experts answer questions about finding the right assessment tool for reporting social determinants of health, choosing CPT modifiers for same-day services, and more.
Anemia describes a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient. Review the types of anemia, diagnostic criteria, treatment, and ICD-10-CM coding.
The National Correct Coding Initiative released the 2024 NCCI Policy Manual in early December, which will be effective January 1. This article covers the changes—both big and small.
After years of working to engage providers and get them on board with CDI efforts, every seasoned CDI professional knows there’s no one-size-fits-all solution.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a broad federal law that establishes the basic privacy and security protections that coders are required to follow.
The 2024 OPPS final rule details changes to price transparency compliance, reimbursement changes and, updates to numerous other hospital programs. Additionally, CMS is moving forward with its proposals to address unlawful payment reductions to 340B drug reimbursement.
Part B physicians will have to prepare for a net 3.4% payment decrease across services in 2024, according to the 2024 Medicare Physician Fee Schedule final rule, which covers numerous operational areas for medical groups, including new coverage opportunities and billing revisions to coding and compliance updates.
As more health systems have been forced to reckon with the undeniable impacts of socioeconomic status on health outcomes, CDI and coding practices have followed in kind. Analyze recent developments with reimbursement and ICD-10-CM coding for social determinants of health (SDOH).
The Journal of the American Medical Association recently released a study that analyzed social determinants of health and other conditions associated with lower-limb amputation in the U.S.’ most populated areas. The study found that several factors corresponded with an increased risk of amputation.
Debbie Jones, CPC, CCA , examines the cause, prognosis, and treatment options for desmoid tumors, in addition to reviewing the ICD-10-CM codes designed to identify them with specificity. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Medical coding practices can vary widely between countries, with different code sets, regulations, and policies governing the process. However, there are some commonalities when comparing medical coding in the U.S. to other countries, which this article explores.
Q: I’ve heard some facilities are beginning to incorporate ICD-11, even though it is not yet implemented in the U.S. How can coders help their providers transition to ICD-11?
The 2024 OPPS final rule details changes to price transparency compliance, reimbursement changes and, updates to numerous other hospital programs. Additionally, CMS is moving forward with its proposals to address unlawful payment reductions to 340B drug reimbursement.
Part B providers will have to prepare for a net 3.4% payment decrease across services in 2024, according to the 2024 Medicare Physician Fee Schedule final rule. The rule covers numerous operational areas for medical groups, including new coverage opportunities and billing revisions to coding and compliance updates.
A recent Office of Inspector General audit of inpatient and outpatient Medicare claims estimated that nearly 20% of cases including codes for abuse or neglect were not reported to law enforcement.
As important changes are coming for physician E/M reporting in 2024, coders should note the changes for reporting telemedicine services, split or shared visits, multiple visits, and hospital or observation care same day admission and discharge. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: What advice can you give pertaining to clinical documentation requirements to properly report CPT codes for vaginal deliveries after cesarean (VBAC) procedures?
Q: How would a coder report a coronary artery bypass graft complicated by ineffective external cardiac device insertion, subsequent removal, and intra-aortic balloon pump placement?
Children diagnosed with acute respiratory distress syndrome (ARDS) had a readmission rate of 27.8% in the first year after discharge, with half of those readmissions occurring within two months, according to a recent study in JAMA Network Open.
Colder weather is approaching, which brings an increase in respiratory infections. Shelley C. Safian, PhD, RHIA, CCS-P, COC, COC-I, clarifies the pathogenic causes of pneumonia, specifically those with recent additions to ICD-10-CM, and those with antibiotic resistance. She also reviews how to report treatment methods in ICD-10-PCS.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, reviews the clinical definition and types of postpartum hemorrhage, the intrauterine treatment devices used to treat it, and relevant ICD-10-PCS coding. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM, delves into the ethical standards, best practices, and importance of accurate health record documentation in regard to heart failure by drawing insights from authoritative sources within the industry.
For certain preventive services, coders must clarify when they become diagnostic services, which is why modifiers -GG, -PT, and -33 exist. Brush up on Medicare policies and CPT codes associated with these modifiers. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Medical coding practices can vary widely between countries, with different code sets, regulations, and policies governing the process. However, there are some commonalities when comparing medical coding in the U.S. to other countries, which this article explores.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, reviews the clinical definition and types of postpartum hemorrhage, the intrauterine treatment devices used to treat it, and relevant ICD-10-PCS coding.
Our experts answer questions about CPT reporting for use of a Jada intrauterine device after delivery, ICD-10-CM coding for other thrombophilia with atrial fibrillation, and more.
Hamilton Lempert, MD, FACEP, CEDC, writes about the complexities of reporting and billing for certain ED services, as well as what coders should watch out for in documentation.
Does the data collected by your healthcare system truly represent the patient you are caring for? Andrew B. Maigur, MD, CHCQM-PHYADV, CMPC, writes about how documentation is critical to capturing data for accurate coding and quality metric reporting.
CMS recently published a summary of its third quarter 2023 HCPCS Level II code update application decisions, accepting 51 of 61 submissions. There were also 10 codes that will be discontinued and one code whose definition will be revised. The additional codes mostly consist of injections and skin substitutes.
Niki Crawford, CCS-P, CPC, RCC, CCP-AS, CCP, QMC, describes a new addition to the Category III CPT code set with add-on code 0715T. She summarizes the procedure, reviews the associated technology, and gives coding tips and a clinical example.
2024 CPT manuals contain several changes related to integrated peripheral and spinal neurostimulator systems. The seven code additions, four code revisions, and new guidelines clarify when coders should use permanent procedure codes from the nervous system chapter vs. a Category III code.
Q: One of our providers used a Jada device on a patient post-delivery, but I cannot find the corresponding CPT code. What is the CPT code for Jada device use?
2024 CPT manuals contain several changes related to integrated peripheral and spinal neurostimulator systems. The seven code additions, four code revisions, and new guidelines clarify when coders should use permanent procedure codes from the nervous system chapter vs. a Category III code.
The decision for an emergency clinician to report fracture or dislocation care CPT codes with an E/M code can have significant reimbursement ramifications. Hamilton Lempert, MD, FACEP, CEDC, explains the complexities of reporting this care and covers details coders should watch out for in documentation.
Despite sepsis being the leading cause of hospital readmissions and in-hospital deaths in the U.S., its extensive history of clinical definitions and criteria can cause confusion for even the most experienced coders. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Kate Siemens, RN, CMSRN, CCDS , discusses the clinical indicators for malnutrition during end-of-life care with Taylor Kuykendall, MS, RD, LD . She covers relevant ICD-10-CM codes and proper reporting methodologies for the condition.
Approximately 33% of patients who experienced a first-time atrial fibrillation (AF) episode while hospitalized for noncardiac reasons had additional AF episodes up to one year after being discharged, according to a study recently published in the Annals of Internal Medicine .
CDI departments have long been involved with the denials management process. As with any expansion of CDI responsibility, those looking to venture into a new area can glean valuable knowledge from those already on the cutting edge.
Niki Crawford, CCS-P, CPC, RCC, CCP-AS, CCP, QMC , describes a new addition to the Category III CPT code set with add-on code 0715T. She summarizes the procedure, reviews the associated technology, and gives coding tips and a clinical example.
The 2024 ICD-10-CM update brought new codes to classify Lafora progressive myoclonus epilepsy and chronic migraines. Review the conditions, symptoms, causes, and reporting requirements of these disorders. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
It won’t take long to train staff on the October NCCI update, says Julia Kyles, CPC . The practitioner procedure-to-procedure edit update that went into effect October 1 deletes eight code pairs and revises 18 code pairs.
Q: Are coders required to report a social determinants of health (SDOH) ICD-10-CM code when a CPT code for an E/M service level is based on medical decision-making (MDM)?
CMS estimated $4.4 billion in improper payments in 2022 for hospital outpatient services, according to a Comprehensive Error Rate Test review recently published in the Medicare Provider Compliance Newsletter. According to the report, of the 1,899 inspected claims, 5.4% were improperly paid.
Despite its benefits, remote work has created obstacles for employees and managers. Healthcare leaders and educators share hard-earned knowledge used to keep their staff and providers’ attention during educational sessions.
A recent Office of Inspector General report found that CMS paid $41.4 million in improper payments to acute care hospitals for claims that were assigned incorrect discharge status codes.
Q: A patient’s previously implanted Impella, a small, catheter-based ventricular assist device, was removed and replaced due to an emergency. How would we report this in ICD-10-PCS and which DRG would it lead to?
Gastroparesis is a condition that affects stomach motility. Sarah Gould, CPC , explains how to report the condition and its complications in ICD-10-CM, in addition to treatment methods in ICD-10-PCS. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , reviews coding, CDI, and clinical validation challenges associated with acute kidney injury cases and gives insight into how coders and physicians can work together to increase accuracy.
CMS' recently implemented October OPPS update brings with it a slew of new, revised, and deleted CPT and HCPCS Level II codes with effective dates ranging from April 18 to October 1. Among the additions are codes for vaccines, vaccine administration, skin substitutes, renal histotripsy, and breast imaging.
Craniosynostosis, a congenital premature fusion of cranial sutures in infants, poses a complex challenge to the child’s appearance and health. Debbie Jones, CPC, CCA , explains the condition, as well as how to report its many types in ICD-10-CM and associated surgical correction procedures in CPT.
Wound care procedure reporting requires coders to follow many specific policies and procedures. This article reviews common wound care techniques of dressing changes, casting, negative pressure wound therapy, and the necessary documentation to report them in CPT. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Coding staff and treating providers can increase E/M code reporting accuracy to ensure their claims hit the mark by reviewing these six Q&As. The material, created by Julia Kyles, CPC , covers medical decision making and time-based coding.
Despite sepsis being the leading cause of hospital readmissions and in-hospital deaths in the U.S., its extensive history of clinical definitions and criteria can cause confusion for even the most experienced coders.
Our experts answer questions about 2024 ICD-10-CM guideline updates for cardiovascular coding, ICD-10-PCS coding for removal of external heart assist devices, and more.
Clinical validation has become one of the hottest targets in payer auditing. Denise Wilson, MS, RN, RRT, writes about strategies facilities can use to appeal clinical validation denials.
Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , reviews coding, CDI, and clinical validation challenges associated with acute kidney injury cases and gives insight into how coders and physicians can work together to increase accuracy.
Critical care coding can challenge both new and seasoned coders. Jessica Miller-Dobbs, CPC, CPC-P, CGIC, offers tips and clarification on reporting critical care services in CPT, as well as sample provider documentation for these services.
Review common wound care techniques of dressing changes, casting, negative pressure wound therapy, and the necessary documentation to report them in CPT.
Our experts answer questions about 2024 ICD-10-CM guideline updates for cardiovascular conditions, documenting social determinants of health, and more.
There is one tell-tale sign that fall is here: the October implementation of the ICD-10 coding updates. Courtney Crozier, MA, RHIA, CCS, CDIP , explains the highlights of the update for fiscal year 2024, including 395 new codes, 25 deletions, 22 revisions, and 131 new headers.
Reporting malnutrition correctly is a constant challenge that faces increasing payer scrutiny. Kate Siemens, RN, CMSRN, CCDS, defines malnutrition and its unique applicability to end-of-life care, documentation tips, and how to report associated conditions in ICD-10-CM. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS recently published an infographic that defines social determinants of health (SDOH), explains the significance of capturing them, and lists which SDOH codes will go into effect October 1.
Kellie Halsted, MSN/MHA, RN, CCDS, CCM , writes about how her experience as a hospital case manager has given her additional insight into writing clinical validation appeal letters as a CDI specialist.
AMA published the 2024 CPT code set with 349 total editorial changes, including 230 additions, 49 deletions, and 70 revisions. The press release announced revisions for immunization/administration sections, E/M clarification, and new Spanish procedure descriptions.
The U.S. has experienced extreme weather events in recent years, including cataclysmic hurricanes and tornadoes. Terry Tropin, MSHAI, RHIA, CCS-P , explains how coders should use and sequence external cause codes in ICD-10-CM for injuries caused by these storms. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Critical care coding can challenge both new and seasoned coders. Jessica Miller-Dobbs, CPC, CPC-P, CGIC , offers tips and clarification on reporting critical care services in CPT, as well as sample provider documentation for these services.
The 2024 Medicare Physician Fee Schedule proposed rule received more than 17,000 stakeholder comments. Julie Kyles, CPC , highlights some of the major concerns that commenters expressed, such as requests for more telehealth policy flexibility and community health integration services.
Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , summarizes the highlights from the newest installment of Coding Clinic, which includes guidance on reporting pancytopenia, inherent conditions, ORIF, and neurally adjusted ventilatory assist devices.
A Journal of Hospital Medicine study published online in August found that decreases in readmission associated with CMS’ Hospital Readmission Reduction Program (HRRP) correlated with an increase in patient mortality for certain conditions.
It can be advantageous for patients and facilities to capture social determinants of health (SDOH) alongside medical conditions. Joscelyn Thomas, RHIT , explains how incorporating screening tools into facilities can help providers and coders promote better health outcomes, reduce disparities, and increase patient engagement.
Building ICD-10-PCS codes for cardiovascular surgery can be tricky given the number of root operations that may apply. Sarah Gould, CPC , reviews cardiac anatomy and ICD-10-PCS guidelines for reporting cardiac insertion and bypass procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS updated its E/M Services Guide in August, reflecting changes for E/M services that went into effect January 1. The guide includes plain-language explanations of policy changes, but some do not align perfectly with AMA guidance.
Providers and coders alike can find NCCI policies challenging to apply. Denise Williams, COC, CHRI , explains the basics of NCCI by defining the initiative, edits, modifiers, and clinical procedure examples.
The 2024 ICD-10-CM update brings almost 400 code changes, including new codes for sickle-cell retinopathy and orbital muscle entrapment. This article delves into the causes, symptoms, and reporting methods for these two ocular conditions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS recently proposed to pay for certain currently bundled caregiver training service CPT codes and three new CPT codes that, if finalized, will be established January 1. Review the criteria of defining a caregiver and which caregiver training services apply.
