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...
Our Town Zoo hosted its annual black tie fundraiser and things got a little, well, wild as the patients at the Fix ‘Em Up Clinic prove. Tiffany made a fashion statement with a bright blue shimmering...
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.
Many physicians say that systemic inflammatory response syndrome (SIRS) criteria are insufficient and confusing at best, and don't indicate whether a patient is truly sick. Some patients may meet necessary criteria for SIRS and truly have sepsis or another severe diagnosis. Others, however, may meet two of four criteria but not actually have SIRS. Where does all of this information leave coders? Often between a rock and hard place. Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, and Robert S. Gold, MD, offer seven tips for coders who need to negotiate tricky sepsis coding.
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?
Depending on the demographics of the region a hospital serves, its coders could determine code assignment for hundreds of deliveries and pregnancy-related services annually. Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, COBGC, and Susan Proctor, RHIT, CCS, CPC, review the relevant coding guidelines for coders who handle coding for these patient encounters.
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.
In ICD-10-CM, coders must report two codes to fully describe certain conditions. They will find “Use additional code” notes in the Tabular List at codes when they need to report a secondary code to...
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...
Gregory House, MD, is hanging up his stethoscope before the transition to ICD-10-CM. I loved House MD when Fox first starting airing it in 2005, but the last few seasons, not so much. Let’s ask Dr...
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.
The American Health Information Management Association (AHIMA) continues to advocate for no delay in the implementation date for ICD-10-CM and ICD-10-PCS.
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.
QUESTION: We are a small anesthesia group and we are concerned about the specificity for ICD-10-CM. If we submit a claim with an unspecified code and the surgeon submits a claim with more specificity, will we still get paid?
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.
Coders often report signs and symptoms when physicians document them in the patient’s medical record. However, coders should not always report additional codes for signs and symptoms. How can coders...
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...
When a physician performs a procedure to enlarge the diameter of a tubular body part or orifice, coders will report root operation dilation with 7 as the third character in the medical and surgical...
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.
Inpatient acute care hospitals could see a 2.3% increase in payment rates under the fiscal year (FY) 2013 Inpatient Prospective Payment System (IPPS) proposed rule, released April 24. The 2.3% is a net update after inflation, improvements in productivity, a statutory adjustment factor, and adjustments for hospital documentation and coding changes.
