Kay Piper, RHIA, CDIP, CCS, details the process of submitting ICD-10-CM codes to the ICD-10 Coordination and Maintenance Committee meeting by sharing the experience a medical coding educator and a CDI physician adviser had when submitting a proposal for the March 2018 meeting.
Keeping up with changing coding guidance adds to the complexity of reporting digestive procedures. In this article, Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , reviews ICD-10-PCS reporting for common digestive procedures including the Whipple procedure and lysis of adhesions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Researchers analyzed reports and clinical data from a community hospital for malnourished patients and concluded that of the 1,817 records for malnourished adult patients examined, 1,171 (64.4%) of them were not coded for malnutrition, according to the study published in the Journal of the Academy of Nutrition and Dietetics.
Laura Legg, RHIT, RHIA, CCS, CDIP, takes a look at some common questions asked about MS-DRG optimization and reviews how inpatient coding and documentation plays a large role in the process.
Karen, a 67-year-old patient with a history of hypertension, diabetes, and tobacco use, presents to her primary care physician with complaints of pain in her right buttock and thigh when she walks from her house to her mailbox. She is then admitted as an inpatient for surgery.
Members of the Medicare Payment Advisory Commission (MedPAC) asked the U.S. Department of Health and Human Services to create national coding guidelines for ED visits by 2022, following an April 4 meeting.
Yvette DeVay, MHA, CPC, CPMA, CIC, CPC-I, writes that in the 2018 OPPS final rule, CMS removed total knee arthroplasty (TKA) from the inpatient-only (IPO) list, effective January 1, 2018. Although some guidance was provided at the time, providers and physicians alike were left confused with a significant number of questions regarding documentation and inpatient status.
Vestibular migraine is a common visual and neurological disorder that can be difficult to diagnose as symptoms of the disorder resemble those of other conditions such as vestibular neuritis and Meniere’s disorder. In this article, Debbie Jones, CPC , reviews clinical indications of vestibular migraine disorder and CPT coding for diagnostic tests used to assess vestibular functioning.
A spinal fusion is a major surgery used to fuse together two or more vertebrae so they can heal into a single bone. This article breaks down spinal anatomy and simplifies CPT and NCCI guidance for reporting spinal fusions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Assigning the appropriate ICD-10-PCS code for spinal procedures can be a challenge for inpatient coders, as they need to correctly assign the entirety of a seven-character ICD-10-PCS code.
Cheryl Manchenton, RN, explains CMS’ Hospital-Acquired Condition Reduction Program (HACRP) and says inpatient coding professionals can play a significant role in HACRP success by understanding the basis for hospital-acquired condition scores and ensuring that documentation and coding accurately and fully captures patient conditions and complications.
Sepsis is a leading cause of death in U.S. hospitals, but in most of cases, sepsis alone may not be the true cause of the majority of inpatient, septic hospital deaths, according to recent research published by the Journal of the American Medical Association.
Q: I know that the tumor, nodes, and metastasis (TNM) staging system can be used for ICD-10-CM coding purposes, but I’ve never used it before. As an inpatient coding professional, should I know how this system works and how to apply it?
A transcatheter aortic valve replacement (TAVR) is an interventional cardiology procedure that has proven to be an important life-saving cardiac intervention frequently seen by inpatient coders. In this article, Stephen Houlahan, RN, MSN, MBA, CCDS, reviews TAVR history, clinical background, and documentation and reimbursement methodologies to ensure proper education and compliance for facilities.
Joe Rivet, JD, CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO, writes that proper reporting and documentation of chronic obstructive pulmonary disease (COPD) will help ensure accurate MS-DRG assignment and strengthen cases during inpatient audits. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Coders often wonder how to define realistic productivity benchmarks. Different facilities establish the responsibilities and expectations of their coding teams, so productivity standards are not uniform.Coders often wonder how to define realistic productivity benchmarks. Different facilities establish the responsibilities and expectations of their coding teams, so productivity standards are not uniform.
Hospital coders must develop and adhere to internal E/M coding guidelines and CPT guidance to accurately report visits to the ED. In addition, because ED coding encompasses professional and facility billing, they may need to scour provider documentation to determine the correct E/M service level for both bill types.
