CMS is proposing two major changes as part of the 2013 Outpatient Prospective Payment System (OPPS) proposed rule , released July 6. One has to do with how CMS proposes to calculate APC relative weights and the other with the reimbursement level for separately payable drugs and biologicals without pass-through status.

QUESTION: Our laboratory medical director sent out a notification to our medical staff, patient care departments, and order entry personnel that a physician order that read “CBC” or “CBC with differential” would be completed as a CBC with automated or manual differential and coded using CPT ® code 85025 (blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC, and platelet count] and automated differential WBC count). Should we code 85025 when the order just reads CBC and when we do a manual differential with the CBC?

One advantage to using ICD-10-PCS is increased specificity. Coders will find increased specificity for the procedure, approach, device, and even anatomical region or body system. In the Medical and...

ICD-10-CM coronary artery disease and myocardial infarction codes will undoubtedly differ from their ICD-9-CM counterparts in some ways, but some aspects will remain the same.

A physician can debride a wound to remove dead, damaged, or infected tissue so the remaining healthy tissue can better heal. Coders need to look for specific information in the documentation of wound debridement.

Robert S. Gold, MD ponders the causes of mechanical and paralytical ileuses.

Learn about ICD-10-CM coronary artery disease and myocardial infarction codes, three-day payment rule audits, malnutrition clinical guidelines, the causes of mechanical and paralytical ileuses, and the importance of documenting the history of present illness.

Inpatient coders don't typically assign E/M codes, but they should be aware of documentation of the history of present illness (HPI).

Pain is an expected component of injuries, illnesses, and surgical procedures. Let's face it, breaking your leg hurts. In some instances, however, the patient's pain is unexpected or is worse than predicted. Sometimes, the pain can last well beyond the time it should have resolved.

Remember when your grade school English teacher drilled the rule of punctuation into your head? Instead of an English lesson, consider this an ICD-10-CM punctuation lesson. Brackets are used in the...

CMS reassigned 10 codes to status indicator K (paid under OPPS; separate APC payment) as part of the July update to the Integrated Outpatient Code Editor .

Chronic kidney disease (CKD) is the permanent alteration in the kidney’s ability to perform filtration and reabsorption functions. Patients with CKD can come into an outpatient clinic or may be admitted as an inpatient, either for the CKD or some other condition. Debra Lawson, CPC, PCS, and Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, explain the ICD-9-CM and CPT ® coding for CKD.

Emergency Departments (EDs) see a wide range of illnesses and injuries, from minor to major, which may require critical care. Lois E. Mazza, CPC, details how critical care is defined, what elements providers must document, and under what circumstances critical care can be coded for ED patients.

The ICD-10-CM makes a distinction between burns and corrosions. The burn codes are for thermal burns, except sunburns, that come from a heat source, such as a fire or hot appliance. You also report e...

QUESTION: A patient was exposed to shingles, for which a coder reported ICD-9-CM code V01.79 (exposure to other viral diseases, including HIV). This poses a problem for billing as code V01.79 is a confidential diagnosis, requiring special release of information from the patient and would remain on the insurance record. As an RN and certified coder, I believed code V01.71 (exposure to varicella) is the correct code because the varicella virus causes both chicken pox and shingles. However, I am being overridden by the chief business office. Which code is correct?

Why do coders need to know about Value Based Purchasing, the Readmissions Reduction Program, and Hierarchical Condition Categories codes? Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, explains why it all comes back to coding accuracy and complete documentation.

Anytown High School held its commencement ceremony over the weekend and it turned out to be a memorable event for more than the usual reason. Class president Marina decided to wear a pair of really,...

The ICD-10-CM Official Guidelines for Coding and Reporting now include guidelines for coding methicillin resistant Staphylococcus aureus (MRSA), so let’s look at how to code MRSA. The physician...

Beginning July 1, coders will have six new HCPCS codes to report for specific drugs and biologicals, according to CMS Transmittal R2483CP .

The Rh factor of positive and negative can lead to problems between a mother and the developing fetus, a condition known as mother-fetus incompatibility. In some cases, the mother must receive the Rho(D) immune globulin. Lori-Lynne A, Webb, COBGC, CPC, CCS-P, CCP, CHDA , explains the diagnostic and procedure coding options for Rho(D) immune globulin.

ICD-10-CM includes some specific guidelines to help coders decide when to code for a current malignancy or a personal history of malignancy. The physician excises a primary malignancy but the patient...

CMS has issued both a National Coverage Determination (NCD) Transmittal 143 and Medicare Claims Processing Transmittal 2473 on the coverage of extracorporeal photopheresis for the treatment of bronchiolitis obliterans syndrome (BOS) in certain circumstances under clinical research studies.

Many HIM directors and coding managers are aware of the decrease in productivity that is anticipated with the implementation of ICD-10. The concern is a valid one, according to Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, who explains what’s ahead and how HIM professionals should prepare.

By now, you may have heard that the ICD-10-CM codes are more specific than those used in the ICD-9-CM system, and fracture coding is one of the areas undergoing the most changes. Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CPC-I, CCDS, discusses fracture coding in ICD-10 and some of the expected documentation challenges associated them.

A patient comes in for a face lift or another cosmetic procedure. What root operation should you code the procedure to in ICD-10-PCS? The answer: alteration (third character 0). The goal of an...

With the increased specificity required for ICD-10-CM coding, coders need a solid foundation in anatomy and physiology. To help coders prepare for the upcoming transition, we will provide an occasional article about specific anatomical locations and body parts as part of a larger series for ICD-10-CM preparation. This month’s column addresses the anatomy of the skull.

Medical necessity denials traditionally focus on high-dollar DRGs, such as those for hip and knee replacements; others may also soon become targets.

Inpatient hospitals will see CMS payment rates increase 2.3% in FY 2013 if the agency finalizes the change in the IPPS proposed rule released in April. CMS expects that in FY 2013, the documentation and coding adjustment will net an aggregate 0.2% increase. Other quality-of-care initiatives could reduce payments.

Will acute respiratory failure be demoted from MCC to CC?

Our coding experts answer your questions about payment for items in OPPS Addendum B and skin substitutes, incomplete documentation for IV infusions, coding for amputation of finger and aftercare, facility codes for peritoneal dialysis

A writer paints a picture with words. The English language alone offers somewhere in the neighborhood of a quarter of a million words. But really how many does the average person use? According to...

The guiding principle is the definitive methodology used for all risk adjustment medical record reviews. Successful Medicare Advantage (MA) plans focus on early disease detection, coordination of care, and accurate reporting of members’ chronic conditions by primary care physicians, retrospective and prospective pursuits to drive and improve health outcomes. Holly J. Cassano, CPC, guides coders through the principles of risk adjustment for MA plans.

Cardiac catheterization is a common procedure performed to study cardiac function and anatomy and to determine if a patient is a candidate for intervention. Terry Fletcher, CPC, CCC, CEMS, CCS-P, CCS, CMSCS, CMC, and Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P, MHP, explain how to code the different catheterization procedures.

When a physician performs a procedure intended to narrow the diameter of a tubular body part or orifice, coders will select the root operation restriction in ICD-10-PCS. Restriction includes both...

CMS released its latest MLN Medicare Quarterly Provider Compliance Newsletter in April. The newsletter features educational information for providers related to recent audit targets and findings.

QUESTION: Our pulmonologists are not comfortable documenting acute respiratory failure unless the patient is on a ventilator. Also, they rarely document chronic respiratory failure, even in chronic obstructive pulmonary disease (COPD) patients on continuous home oxygen. I’m trying to develop standard query forms for acute and chronic respiratory failure and am running into these obstacles. How do you recommend handling this problem?

Do not view the proposed rule extending the ICD-10 implementation date from October 1, 2013, to October 1, 2014, as a year-long break from ICD-10 preparations. Rather, focus on using the additional time allotted to your advantage. This includes conducting documentation and coding assessments to gauge ICD-10 readiness. Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, explains why—and how—facilities should start assessing the readiness of their coding staff and documentation procedures in relation to ICD-10 requirements and create strategies to manage any deficiencies.

So we’ve survived the zombie apocalypse, but we’re not out of the undead woods yet. It seems a group of vampires is trying to one-up the zombies. But, never fear, vampires can actually be regular...

Coders will need very specific information in order to code for fractures in ICD-10-CM, including the type of fracture, specific bone fractured, and whether the patient is seen for an initial or subsequent visit. Robert S. Gold, MD, Sandy Nicholson, MA, RHIA, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, detail the information physicians must document for accurate fracture code assignment.

Coders and clinicians often seem to speak different languages. What a clinician considers important information may not be what a coder needs to assign the correct code. Clinicians may not document a piece of information that is vital to the coder. Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, Joseph Nichols, MD, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, explain how clinicians and coders can work together to improve communication.

With the increased specificity required for ICD-10-CM coding, coders need a solid foundation in anatomy and physiology. To help coders prepare for the upcoming transition, we will provide an occasional article about specific anatomical locations and body parts as part of a larger series for ICD-10-CM preparation. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, takes coders on a trip through the digestive system.

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. ICD-10-CM coding conventions for such conditions require coders to report...

While we know the implementation date of ICD-10 may change to the proposed 2014 deadline, healthcare organizations must keep moving forward with preparations. Annie Boynton, BS, RHIT, CPC, CCS, CPC-H, CCS-P, CPC-P, CPC-I, CPhT, explains how organizations can use the additional time to better handle the change process associated with ICD-10, especially planning for education and training.

QUESTION: A physician documents in an operative report debridement of a necrotic muscle (not due to an open wound). Must the physician also document how the muscle is removed to report ICD-9-CM procedure code 83.45 (other myectomy)? Is this considered excisional or nonexcisional debridement? What documentation is required to code the removal of a necrotic portion of a muscle?

Home repair and improvement can be hazardous to your health. Just ask the residents of Calamity Condos who are visiting the Fix ‘Em Up Clinic. Tom and Wendy decided to repaint the living room of...

When a physician determines the patient has a coronary artery blockage, the physician can choose from several options for treating the patient, depending on exactly what is wrong. John F. Seccombe, MD, and Betty Johnson, CPC, CPC-I, CPC-H, CPCD, CCS-P, PCS, CCP, CIC, RMC, discuss invasive and non-invasive treatments, as well as the heart’s anatomy.

CMS did not discuss drug administration services in the 2012 OPPS final rule, but the AMA did make significant additions to the CPT ® coding guidelines in the 2012 CPT Manual . Jugna Shah, MPH, and Kimberly Anderwood Hoy, JD, CPC, review the guidelines and explain the nuances to keep coders up to date.

QUESTION: Can you explain the difference between modifier -80 (assistant at surgery by another physician) and –AS (physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery)? Medicare requires us to use both modifiers for our physician assistants. We have been instructed to use -AS first and -80 second for all Medicare claims submissions. Is this correct?

Coders will need more information in order to code for fractures in ICD-10-CM. For instance, the physician must document which specific bone is fractured, including which side of the body. They will also need to document whether the patient is seen for an initial or subsequent visit.