Q: A patient is admitted with a high white blood count, tachycardia, tachypnea, and chills. The blood culture shows positive for methicillin-resistant Staphylococcus aureus (MRSA). The attending physician documents MRSA sepsis in the progress notes. Antibiotics are changed based on the blood culture and the patient is treated with appropriate antibiotics. Due to poor vascular access, a central venous catheter (CVC) is inserted and antibiotics are infused through this access. The patient responded slowly to treatment and CVC access becomes red and inflamed. The catheter is removed and cultured. The physician documents this to be an infection due to MRSA. What’s the diagnosis code for this?
The first day of AHIMA’s ICD-10 and CAC Summit is in the books and although attendance is down this year, the speakers have provided some good food for thought. Here are some briefs highlights from...
Don’t blame the AMA for the most recent ICD-10 delay, says Steven Stack, MD , immediate past chair of the AMA Board of Trustees. Stack gave the keynote address at the AHIMA ICD-10 and CAC Summit in...
Coding for pressure ulcers in ICD-10-CM requires precise documentation of the ulcer’s location, which really shouldn’t surprise anyone. ICD-10-CM includes increased specificity for almost every...
Here comes Peter Cottontail, hopping down the bunny trail—and right into a gopher hole. Stupid rodents. Poor Peter limped his way into the Fix ‘Em Up Clinic to see Dr. Hop A. Long for an initial...
A patient undergoes a hysterectomy and experiences post-procedural bleeding. The surgeon cauterizes the bleed and evacuates a blood clot. In ICD-10-PCS, how do you code the cauterization? With the...
Don’t look now, but mumps are making a comeback . How do we code mumps in ICD-10-CM? Pretty much the same way we code them in ICD-9-CM. The codes just look a little different. In ICD-10-CM, we can...
Plenty of uncertainty surrounds the ICD-10 implementation delay, but healthcare organizations shouldn’t put the brakes on their plans. Cheryl Ericson, MS, RN, CCDS, CDIP , William E. Haik, MD, FCCP, CDIP , Monica Lenahan, CCS , Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and James S. Kennedy, MD, CCS, CDIP, offer thoughts on how to keep moving forward with ICD-10.
In the wake of the latest ICD-10 implementation delay, coders and other healthcare professionals are looking for ways to continue with their implementation and training. They are also looking for ways to minimize the disruptions the delay may cause.
On the surface, you may think that transitioning from ICD-9-CM to ICD-10-CM for reporting schizophrenia, schizoid personality, and bipolar disorders is a dramatic change. However, Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, reveals that with some minor adjustments, the change can be a smooth one.
Q: Our physicians document a diagnosis of pneumonia but do not normally make a specific connection with the patient's ventilator status, even when this is obvious from the record. For example, the patient's been on the ventilator support immediately prior to the diagnosis. Can I report this as ventilator-associated pneumonia in ICD-10-CM without the documentation specifically connecting the conditions?
ICD-10-CM includes more specificity than ICD-9-CM, but it still includes unspecified codes. Adele Towers, MD, MPH, Joanne Schade-Boyce, BSDH, MS, CPC, ACS, PCS, Michael Gallagher, MD, MBA, MPH, Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC , and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, explain when reporting an unspecified ICD-10-CM code is a good option.
Sometimes a physician just needs to take a look around a body part and see what’s what. If the physician’s sole objective is to examine a body part, either visually or manually, report the procedure...
We know we're facing at least a one-year delay in ICD-10 implementation. What you with that time? will directly affect how prepared you are for the eventual ICD-10 implementation. Here are some...
What a wild 12 days. On March 25, we were all preparing for the six-month-to-implementation milestone April 1. Some people were looking forward to that milestone more than others, but we had a plan...
If you code for pregnant patients and newborns, you may occasionally wonder which record to code a condition on. Is it something you code for the mother or for her offspring? ICD-10-CM divides the...
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, explains how reporting multiple gestations will change in ICD-10-CM, including greatly expanded specificity and replacements for V codes from ICD-9-CM.
On Monday, the Senate passed a House of Representatives bill on Medicare payments that included a provision to delay ICD-10 implementation until at least October 1, 2015.
Q: My question is about the time interval requirement of the CPT ® add-on code 96376 (each additional sequential intravenous push of the same substance/drug provided in a facility [list separately in addition to code primary procedure]), which says that more than 30 minutes must pass between administrations of same substances in order to report it. In our ED, cardiac patients are frequently started on heparin—a bolus given for less than 16 minutes and a drip given over several hours. These are frequently charted in the electronic record as having been given at the same time. In this case, is it still appropriate to report 96365 (intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour) for the first hour of drip and 96376 for the bolus, or must the administration be given greater than 30 minutes apart?
