Physicians use a lot of shortcuts and abbreviations. Some of them may even make it to the official abbreviation list at a hospital. Some don't. Even if they do, some physicians will use the wrong term.
Malnutrition is at its most basic level any nutritional imbalance. While it can be overnutrition, such as being overweight, obese, or morbidly obese, providers more commonly equate malnutrition with undernutrition, which is a continuum of inadequate intake, impaired absorption, altered transport, and altered nutrient utilization.
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician documentation to accommodate the new code set was a top concern for the healthcare industry.
ICD-10-PCS codes consist of seven characters, each of which identifies a unique, specific piece of information. For most of the codes in the Medical and Surgical section, each character represents the same information every time.
Ghosties and ghoulies and long-legged beasties are parading through the Fix ‘Em Up Clinic. It must be Halloween and the staff Halloween party. Even the best planned Halloween party can go astray (...
Once upon a midnight dreary, as I labored on a query To send to the doc whose documentation was a source of constant woe As I nodded, nearly napping (that darn G47.411 again) Suddenly there came a...
Ewww, I don’t think so. Your feet stink. What could be causing that foul odor to emanate from your feet? The most common cause is sweat. Just sniff your old gym sneakers and you’ll see what I mean...
Steven Espinosa , CCS , AHIMA-approved ICD-10-CM/PCS trainer, and Denise Williams, RN, CPC-H, outline the anatomy of the upper gastrointestinal system and how anatomical details, along with the provider's approach and intent, help determine the proper procedure code.
Q: Do any general guidelines exist for queries on outpatient services? We are beginning the process of developing such a query system for our hospital outpatient services and clinical documentation team.
When is a mammogram a screening procedure and when does it qualify as a diagnostic test? Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, outlines the differences between the two and what to look for in the documentation.
Coders aren’t the only ones who run into problems due to a lack of complete physician documentation. Lack of sufficient documentation also causes problems for audit review of submitted claims, which in turn leads to delays in payment, according to the October 2014 Medicare Quarterly Provider Compliance Newsletter .
With the increased specificity required for ICD-10-CM coding, coders need a solid foundation in anatomy and physiology. Review the anatomy of the thoracic cage and coding concepts in ICD-10-CM related to coding diagnoses of this region.
When coders run into a tough coding question, they often look for guidance in the AHA’s Coding Clinic . Coding Clinic is a resource, but it’s not always the final word. The AHA publishes Coding...
Poor Mr. Frank N. Stein. He just coughed up a lung. Literally. While it is possible to survive on one lung, it’s generally not recommended, so Frank is here at the Stitch ‘Em Up Hospital to get a new...
If I hear one more person poke fun at ICD-10-CM code V97.33XD (sucked into a jet engine, subsequent encounter), I am going to develop a very strong case of R45.850. (That’s homicidal ideation in case...
A large number of the code additions in ICD-10-CM appear in the musculoskeletal section. While fractures account for some of those changes, coders also need to understand how coding for other orthopedic conditions will change in ICD-10-CM. Kristi Stanton, RHIT, CCS, CPC, CIRCC, and Kim Carr, RHIT, CCS, CDIP, CCDS, discuss ICD-10-CM coding for sprains, strains, and dislocations.
Q: How specific does the physician have to be for the location of the acute myocardial infarction (MI) in ICD-10-CM? We don’t do catheterizations at my facility .
When a physician closes off varices, coders must determine the location and method the physician used to correctly build an ICD-10-PCS code. Nena Scott, MSEd, RHIA, CCS, CCS-P, and Gretchen Young-Charles, RHIA, review the components of different procedures for closing off varices and how to code those procedures in ICD-10-PCS.