A common question that coders often ask is when to report a secondary diagnosis. In part two of this two-part series, Gloryanne Bryant, RHIA, CDIP, CCS, CCDS , looks at the chapter-specific coding guidelines related to secondary diagnosis coding found in the ICD-10-CM Official Guidelines for Coding and Reporting.
Nearly one-third of the world’s population is overweight or obese, including an estimated 160 million Americans, according to the Institute for Health Metrics and Evaluation . These statistics are alarming, especially considering that obesity is linked to many other conditions such as heart disease, stroke, Type 2 diabetes, and certain types of cancer.
Inpatient coding audits are performed for different purposes by individuals within and outside of the hospital. Coding audits can be categorized in various ways as shown below, but these attributes are not exclusive: Audits will have several characteristics at a time.
Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRD, CCDS, writes that while the fiscal year (FY) 2019 IPPS proposed rule is considering the downgrade of ICD-10-CM code B20 (human immunodeficiency virus [HIV] disease) from an MCC to a CC, it does not mean that diagnosing and coding for HIV has lessened in complexity.
A common question that coders often ask is when to report a secondary diagnosis. In part one of this two-part series, Gloryanne Bryant, RHIA, CDIP, CCS, CCDS , looks at the general coding guidelines related to secondary diagnosis coding found in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting.
It is well known that ICD-10-CM/PCS code assignment impacts hospital reimbursement and compliance; however, there is an additional code that often flies under the radar for inpatient coders—the discharge status code. Inaccurate discharge status code assignment for Medicare post-acute care transfers (PACT) can lead to under reimbursement and compliance risks for hospitals.
The thyroid gland, included in the endocrine system, is a small gland located at the base of the neck. Although small when compared to the other components of the endocrine system, the thyroid gland plays a significant role in overall body function, influencing the performance of the heart, brain, liver, kidneys, and skin.
A diagnosis of autism spectrum disorder (ASD) now includes several conditions that used to be diagnosed separately: autistic disorder, pervasive developmental disorder not otherwise specified, and Asperger’s syndrome. Peggy Blue, MPH, CCS, CCS-P, CPC, CEMC , reviews these terms to aid accurate coding. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Allen Frady, RN-BSN, CCDS, CCS, CRC, writes about guidance related to documenting acute respiratory insufficiency and gives tips to coders and CDI teams on what to do when the conditions are over-documented postoperatively.
James S. Kennedy, MD, CCS, CDIP, CCDS, writes that the various approaches hospital systems use to optimize their DRG-based case-mix index or HCC-based risk adjustment factor scores will likely conflict with how an accountability agent will see those measurements.
James S. Kennedy, MD, CCS, CCDS, CDIP, writes that clinical validity, documentation, and ICD-10-CM coding applicable to liver disease remains a great challenge to those invested in severity and risk-adjustment coding compliance. In this article, he reviews several pitfalls that could await facilities.
Danielle Richmond says that while inpatient coder shortages are nowhere near what they were with ICD-9-CM, new challenges have emerged. This article shares important advice for any managers trying to improve their coder recruitment and hiring process.
Coders often seek definitions for realistic productivity benchmarks, and standards depend on how a given facility establishes the responsibilities and expectations of its team. Therefore, before assessing a coder’s success, a facility must set goals that define that success. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, writes that even though CDI specialists are not coders, it’s important to learn the rules and guidelines that coders follow. CDI teams need to reference guidance and guidelines in their daily work to ensure documentation is clear, concise, and supportive of accurate code assignment true to the patient’s story.