Julian Everett, RN, BSN, CDIP , details the updated pediatric sepsis recommendations presented by the Surviving Sepsis Campaign which provides insight for clinical documentation specialists and inpatient coders on current clinical practices for the treatment of pediatric severe sepsis and septic shock.
Q: Is there is any guidance on ICD-10-CM reporting for screening for COVID-19? For example, a patient was admitted with pneumonia and the physician documented “COVID-19 screening completed–NEGATIVE.” Would it be appropriate to assign ICD-10-CM code Z11.59 (encounter for screening for other viral diseases) for this?
CMS and the Centers for Disease Control and Prevention (CDC) announced a new ICD-10-CM code for reporting COVID-19 along with relief for facilities participating in quality reporting during COVID-19. Guidance on MS-DRG assignment and CC/MCC status for the new COVID-19 code has also been released.
Amy Sanderson, MD , writes that cerebral edema and brain compression are the result of significant brain abnormalities that can be life-threatening, and it’s important for clinicians to recognize and treat these conditions promptly. Properly documenting these diagnoses in the medical record is important to accurately reflect just how sick these patients are.
Sarah Nehring, CCS, CCDS, reviews ICD-10-CM reporting for the novel coronavirus (COVID-19) as well as ICD-10-PCS reporting for procedures such as mechanical ventilations, tracheostomies, and extracorporeal membrane oxygenations. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Why delve into psychiatric record review? For some programs, the expansion into psychiatric units or facilities may be driven by the needs of the patient population, says Rhonda Mark, RN, BS, CCDS , a CDI specialist at Cleveland Clinic Indian River Hospital in Vero Beach, Florida.
Providence St. Joseph Health, which cared for the first U.S. novel coronavirus (COVID-19) patient, is sharing how the health system has responded to the crisis.
The Centers for Disease Control and Prevention (CDC) is monitoring the rapid spread of a disease caused by the 2019 novel coronavirus, formally named COVID-19 . Recently, the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic.
Under both the 1135 waiver and the Coronavirus Preparedness and Response Supplemental Appropriations Act, CMS is increasing access to Medicare’s telehealth services to allow beneficiaries to receive professional healthcare services without having to travel to a healthcare facility.
The AMA announced that its CPT® editorial panel expedited approval of a unique CPT code to report laboratory testing services for COVID-19. The new code supports the urgent public health need for streamlined reporting of testing for the virus.
Providers will find immediate opportunity to provide virtual visits to patients enrolled in Medicare and Medicare Advantage plans as CMS seeks to facilitate screening and treatment of novel coronavirus (COVID-19) cases.
Approximately 12% of Americans suffer from migraine headaches, according to the Migraine Research Foundation. In this article, Shelley C. Safian, PhD, RHIA, CCS-P, CPC-I, reviews coding for migraine headaches and their treatment, including CPT reporting of drug-free alternative treatment options.
Given the frequency with which wound procedures are performed, and the expenses associated with their performance, it’s essential that coders have a clear understanding of how to accurately report CPT codes for these services. Review 2020 CPT codes for wound repairs and grafting procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: We are seeing an influx of possible COVID-19 patients at our facility. How can we prepare to query for COVID-19-related documentation and coding issues that are bound to come our way due to the newness of the diagnosis?
Kay Piper, RHIA, CDIP, CCS, says exciting changes to ICD-10-CM are published in an often-overlooked document called the Addenda. It lists additions, revisions, and deletions to the Alphabetical Index and Tabular List. This might seem mundane until you realize the changes’ potential effect on coding and CDI.
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, details Chapter 5 of the ICD-10-CM manual which contains codes for mental, behavioral, and neurodevelopmental disorders, and says attention must be paid to coding guidelines and instructional notes when reviewing these codes for inpatient assignment.
Yvette DeVay, MHA, CPC, CPMA, CIC, writes that because novel coronavirus (COVID-19) is a new disease, there is still much to learn about how the disease is spread and what severity of illness it causes. For these reasons and more, many inpatient coders are finding this virus hard to report. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
When reporting CPT codes for spinal excisions and decompression procedures, coders must consider the approach used, spinal levels operated on, number of providers involved, and more. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Providers need to clean up coding for electro-acupuncture devices, according to CMS. In Special Edition MLN Matters 20001, the agency noted that some providers are incorrectly coding these devices using HCPCS Level II code L8679 (implantable neurostimulator, pulse generator, any type).
Coders will find a wide range of CPT and HCPCS Level II codes that have been assigned medically unlikely edits (MUE) this year. Review new MUE values that went live January 1 for codes involving drug injections as well as E/M, radiology, and therapy services.
Hemorrhoids are the third most common outpatient gastrointestinal diagnosis in the U.S., according to the National Institute of Diabetes and Digestive and Kidney Diseases. Debbie Jones, CPC, CCA , writes about symptoms of hemorrhoids and CPT coding for treatment.
Q: We are seeing more fundoplication surgeries and esophageal sphincter augmentation procedures for patients with gastroesophageal reflux disease at our hospital. Do you have any tips for our coders when reporting these procedures in ICD-10-PCS?
The Surviving Sepsis Campaign recently published new pediatric sepsis guidelines in Pediatric Critical Care Medicine . This update includes information on a two-phase process for septic shock and guidelines for therapy start times.
Sharme Brodie, RN, CCDS, CCDS-O, covers the guidance published in the Fourth Quarter 2019 issue of Coding Clinic , which includes updates for atrial fibrillations, pressure-induced deep tissue damage, and more.
William E. Haik, MD, FCCP, CDIP , details guideline changes regarding the diagnosis and treatment of adults with community-acquired pneumonia and provides criteria to clinically validate a diagnosis of Gram-negative and methicillin-resistant Staphylococcus aureus (MRSA) pneumonia.
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , reviews instructional notes and reporting guidance for ICD-10-CM codes in Chapter 3 of the manual, which includes codes for diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Like other services covered by Medicare, observation must be reasonable and necessary or, in other words, medically necessary. The physician must document that they assessed patient risk to determine that the patient would benefit from observation services.
To enhance efforts to combat the opioid crisis in America, CMS policy allows for a new benefit under Medicare Part B concerning Opioid Treatment Programs.
Prior to 1983, Medicare reimbursed based on actual charges that inpatient healthcare facilities billed (often referred to as “fee-for-service” payments). The more tests, procedures, and services ordered by physicians, the more an organization was paid. This created the potential for unnecessary or excessive services, contributing to rising healthcare costs and the possibility of depleting Medicare funds.
The fiscal year (FY) 2020 ICD-10-CM Official Guidelines for Coding and Reporting, released shortly after the FY 2020 ICD-10-CM code release, provide instructions for healthcare professionals on how to appropriately report complex diagnoses. Since FY 2020 is in full swing, now is the time to review these updates if your inpatient coding team hasn’t already.
The Centers for Disease Control and Prevention (CDC) released an important report in November 2019 on antibiotic-resistant threats in the United States. This comprehensive look at the serious problem of antibiotic resistance has compelling individual stories, great graphics, and actions that healthcare institutions can take to help deal with the issue. The report is free to download. I recommend it for professionals who work in documentation and coding as the information can be applied immediately in your work environments.
ICD-10-CM/PCS coding for severe and potentially fatal heart conditions such as aortic valve stenosis (AVS), heart failure (HF), and atrial fibrillation (AF) requires an in-depth understanding of anatomical terminology and clinical indications. Coders need to be able to select the most specific codes based on reported symptoms and the severity of the disease.
The Centers for Disease Control and Prevention (CDC) is monitoring the rapid spread of a novel 2019 coronavirus, formally named COVID-19, first identified in Wuhan, Hubei Province, China. On January 30, the International Health Regulations Emergency Committee of the World Health Organization (WHO) declared the COVID-19 outbreak a public health emergency of international concern due to its sustained person-to-person spread within countries and across continental borders.
The Centers for Disease Control and Prevention is monitoring the rapid spread of a novel 2019 coronavirus, formally named COVID-19, first identified in Wuhan, Hubei Province, China. Learn about signs, symptoms, and ICD-10-CM coding for the virus. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS announced on February 13 that it created a new HCPCS code U0001 to report laboratory testing for the 2019 novel coronavirus (COVID-19). Medicare’s claims processing system will be able to accept this code on April 1 for dates of service on or after February 4.
CMS recently announced that it will cover acupuncture therapy sessions for Medicare patients with chronic low back pain. Read about how this change will impact physician coding and billing for acupuncture services.
More than 34 million people in the U.S. have diabetes and one in five don’t know they have it, according to the Centers for Disease Control and Prevention. In this article, Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC , writes about E/M coding for diabetes management and HCPCS Level II coding for external insulin infusion pumps.
In 2017, roughly 48 million incident cases of sepsis were recorded worldwide and 11 million sepsis-related deaths were reported, according to a study published in The Lancet . According to the study, this represents 19.7% of all global deaths.
While the premise for quality programs is largely the same across the board, there are many programs and measures that fall under the “quality” banner. From readmissions to present on admission (POA) and patient safety indicators (PSI), CDI programs have a myriad of potential options in terms of record review focus.
Julian Everett, RN, BSN, CDIP , says that 2020 should be the year when more CDI programs and inpatient coding teams ponder the idea of expanding into reviewing obstetrics. In this article, Everett details key areas to consider when starting these reviews, including hiring staff that have experience in obstetrics, conducting case sample assessments, and providing education on coding guidelines.
Sarah Nehring, CCS, CCDS , writes that because of the complexity and frequency of ischemic stroke admissions, inpatient coders should review clinical criteria and ICD-10-CM reporting regularly for this diagnosis to ensure accurate coding and reimbursement. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
