A complication basically refers to an unexpected result, outcome, or event. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, Cheryl Ericson, MS, RN, CCDS, CDIP, and Trey La Charité, MD , detail when to report a complication and highlight the differences in complication coding between ICD-9-CM and ICD-10-CM.
CMS Transmittal 3217 , effective April 1, will allow inpatient-only procedures to be included on inpatient claims, similar to other outpatient services included in the three-day window.
Poor Wendy. Shortly before Christmas, she stubbed her toe, really hard. However, no bruise appeared and her toe didn’t swell up, so she thought nothing of it. Three weeks later, she stretched her...
You have one more chance to participate in CMS’ end-to-end testing. The agency is currently looking for approximately 850 volunteers for the June 1-5 testing week. You can volunteer on your MAC’s...
Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, discusses how to code for burns and corrosions in ICD-10-CM, which requires at least three codes to indicate the site and severity, extent, and external causes.
Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, and Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD, look at frequently diagnosed mental disordersand note changes for reporting them in ICD-10-CM.
Cardiovascular coding can be challenging even without the introduction of new codes and concepts in ICD-10-CM. Laura Legg, RHIT, CCS, and Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, review the anatomy of the cardiovascular system and highlight some of the key changes in ICD-10-CM.
Q: Our electronic health record system only provides for a "yes/no" choice under smoker. How can we capture the additional details necessary for an ICD-10-CM code assignment?
Providers who want to volunteer to participate in CMS' final round of ICD-10 end-to-end testing have until April 17 to sign up through their Medicare Administrative Contractor's (MAC) website.
Liam spent this St. Patrick’s Day on a fruitless quest for a pot of gold. He powered up for his quest by having a few glasses of green Guinness beer for breakfast. Turns out it’s not a good idea to...
Poor Wile E. Coyote is headed for surgery. As you might recall, Wile E. suffered a subdural hematoma following a collision with a cliff on Friday the 13th. Dr. Frankenbean decided to try conservative...
Poor Wile E. Coyote, Friday the 13 th has not been kind to our favorite super genius. Wile E. arrived at the Acme ED decidedly the worse for wear after his latest encounter with a certain speedy bird...
Myths and misinformation about query practices still remain. Cheryl Ericson, MS, RN, CCDS, William E. Haik, MD, FCCP, CDIP, CDIP, and Nelly Leon-Chisen, RHIA, provide a refresher on how and when to query physicians.
Clinical documentation improvement (CDI) specialists must understand CMS pay-for-performance measures in order to improve data quality . Shannon Newell, RHIA, CCC, AHIMA-approved ICD-10-CM/PCS trainer, Steve Weichhand, and Sean Johnson explain how Patient Safety Indicator 90 is measured and what role CDI specialists play in capturing data for this measure.
Three university hospitals saw a doubling of Recovery Auditor audit activity from 2010–2011 to 2012–2013, and a nearly three-fold increase in overpayment determinations, according to a new study in the Journal of Hospital Medicine.
Q: How should the diagnosis of urinary tract infection (UTI) and encephalopathy be sequenced, specifically which diagnosis should be the principal? If physician documentation indicates that the patient came in with confusion, can encephalopathy be assigned as the principal diagnosis if it is due to the UTI and no other contributing issues are present?
ICD-9-CM and ICD-10-CM differentiate between acute and chronic meniscus tears. Kristi Pollard, RHIT, CCS, CPC, CIRCC , and Gretchen Young-Charles, RHIA, review how to code these injuries in both systems.
Melissa took her four nephews sledding over the weekend to the boys’ delight. They had a great time. Aunt Melissa, however, didn’t escape the adventure unscathed. While descending the (not really)...
We want physicians to be very clear in their documentation about what’s wrong with the patient and what the physician did to make that patient better. Our friends over at the Association of Clinical...
A new article in the Journal of the American Medical Association (JAMA) Psychiatry shows a strong link between genetics and autism. That’s not an unusual or completely unexpected outcome. Scientists...
