With advice from three certified medical professionals, CDI specialists and healthcare providers can develop relationships that foster a culture of collaboration and continuous improvement in documentation and coding practices.
Review a recent OIG audit which found that without strengthening program safeguards, CMS and its contractors may not be able to prevent or detect improper payments for short inpatient stays or recover overpayments for claims that do not comply with Medicare requirements.
Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, provides an overview of toxic encephalopathy including signs and symptoms, diagnosis and treatment, and relevance for coding professionals and CDI teams.
When an office/outpatient visit is coded based on time, think beyond face-to-face time to get full credit. This article reviews time-based coding, how to count time, which activities count toward time, and which ones don’t. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Critical access hospitals ensure that people living in remote, rural, or underserved communities still have access to medical care. Learn about the ins and outs of their reimbursement models and other billing and coding considerations.
According to a recent analysis, healthcare organizations are submitting more prior authorization requests to Medicare Advantage plans and more of those requests are being denied. Review the analysis’ findings to be more aware of prior authorization processes and CMS’ efforts to streamline them.
The connection between medical necessity and diagnosis coding should be included with your training on the 2025 update to the ICD-10-CM code set. This article serves as a refresher on medical necessity, possible ICD-10-CM conflicts, and other best practices.
Q: How do I know when to use CPT code 26370 vs. 26356, for a finger tendon repair? Is it based on whether there is an intact flexor digitorum superficialis (FDS) tendon, or whether the cut or laceration of the flexor digitorum profundus (FDP) tendon was in Zone II?
Work with pharmacists to make sure patients who receive antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection prevention don’t miss a treatment when CMS implements the national coverage determination (NCD) for a new preventive service that includes pre-exposure prophylaxis (PrEP) for HIV.
The decision to implement AI in one’s health system is no small matter, but Katie Parsley, MSN, RN, CCDS, CPHQ, a CDI manager at Providence Health and Services in Oregon, shows how technology solutions employed at her organization have had an overall positive impact on clinical accuracy, prioritization, querying, and the efficiency of CDI staff.
Our experts answer questions on linking cellulitis and diabetes, coding COPD and associated conditions, and applying clinical criteria guidelines for sepsis.
With advice from three certified medical professionals, CDI specialists and healthcare providers can develop relationships that foster a culture of collaboration and continuous improvement in documentation and coding practices.
Being able to differentiate between the types of colonoscopy procedures in outpatient settings is essential to ensure that the correct codes are documented. This article reviews the main types of colonoscopies and the factors that determine how they are coded.
The majority of U.S. healthcare organizations struggle with denials and underpayments in all care settings, making it difficult to keep up with a meaningful manual appeals process. Learn how coding professionals can leverage technology to accurately capture and validate clinical data, ensuring proper coding and documentation while reducing the likelihood of denials.
A cohort study published in the Journal of the American Medical Association found that the detection of incident stroke events is moderately accurate when using ICD-10-CM codes in Medicare claims and very accurate in ruling out non-stroke cases.
Malnutrition affects millions of people across all age groups, and to better discuss and understand the coding nuances of malnutrition, Cokethia Rachel, CPC, CCS, CPMA, SSBBP, demonstrates how coders should define the condition, appropriately review relevant documentation, and recognize when the medical necessity of malnutrition has been supported. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Alba Kuqi, MD, MSHIM, RHIA, CCM, CRCR, CICA, CSMC, CSAF, CCS, CCDS, CDIP, explores common reasons for sepsis-related denials, offers strategies for effective documentation and coding, and presents approaches to successfully appeal these denials.
Q: Video colonoscope was advanced through a patient’s rectum to the cecum where there was normal-looking mucosa throughout. The patient had scattered diverticula in the sigmoid colon and a 6-mm sessile polyp in the proximal rectum that was removed completely by hot biopsy technique. Surgeon documented to await pathology report. How would this operative note be reported in ICD-10-CM and ICD-10-PCS?
Being able to differentiate between the types of colonoscopy procedures in outpatient settings is essential to ensure that the correct codes are documented. This article reviews the main types of colonoscopies and the factors that determine how they are coded. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: What ICD-10-CM code should we report for a periprosthetic fracture due to an injury? Do you use the S codes for a traumatic fracture with a secondary code for replacement, or do you select a code from the M97 (Periprosthetic fracture around internal prosthetic joint) category?
The ICD-10-CM changes for fiscal year 2025 are coming October 1, 2024. Learn about some of the changes to guidelines, notes, wording in current categories, and expansion of code categories.
Patients who self-reported housing instability often didn’t have the correct ICD-10-CM codes documented in their record, according to a recent study. Review the results of the study and be more aware of the importance of properly documenting housing insecurity to ensure appropriate housing and medical services are delivered.
A recent draft local coverage determination includes detailed coverage requirements for chronic migraine treatment. This article reviews the terminology that drives migraine coding.
Teresa Brown, RN, CCDS, CDIP, CCS, explores the significance of the Elixhauser Comorbidity Index in enhancing our understanding of patient health profiles and supporting informed decision-making across various facets of healthcare delivery.
CMS released the FY 2025 IPPS final rule on August 1, which seeks to address key social determinants of health and strengthen emergency preparedness. This rule updates Medicare payments and policies for discharges from inpatient hospitals beginning October 1, 2024.
Q: A patient is in the postpartum period after delivering a healthy baby girl. She developed diabetes mellitus during the pregnancy. She is being treated with Metformin, an oral hypoglycemic drug. How would this situation be reported in ICD-10-CM?
Amid the myriad of conditions and diseases, probable catheter-associated bloodstream infections emerge as a focal point for clinical intervention and revenue cycle efficiency. Pooja Patwal, MBBS(MD), CCS, CDIP, CHCQM , explores how capturing accurate ICD-10 codes for probable BSIs is paramount for healthcare facilities striving for excellence in patient outcomes.
Chronic conditions pose significant challenges to individuals and healthcare systems alike, often leading to reduced quality of life, increased healthcare costs, and rise in mortality rates if left unmanaged. Proper documentation of chronic conditions, however, can help facilitate communication, coordination, and continuity of care for patients from healthcare providers. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: What are some of the common documentation pitfalls or missteps related to pediatric malnutrition? And what can CDI specialists do to address them proactively?
Stand-alone and integrated physician practices have unique challenges and requirements regarding revenue cycle management. Discover how revenue integrity programs in professional fee settings are designed and function.
With CMS’ release of its proposed 2025 Medicare physician fee schedule, the agency proposed many policy changes and revisions. Explore several of them and other announcements made by CMS.
CMS’ proposed rule to revise the Medicare hospital Outpatient Prospective Payment System for calendar year 2025 has been released. Review some of the proposals that could directly impact your organization.
Gain unique and fresh insights from clinical documentation integrity professionals in unique settings to help you strengthen your organization’s denials management efforts.
Teresa Brown, RN, CCDS, CDIP, CCS, explores the significance of the Elixhauser Comorbidity Index in enhancing our understanding of patient health profiles and supporting informed decision-making across various facets of healthcare delivery.
Organizations need to decide how to manage the clinical validation conundrum effectively and consistently. Trey La Charité, MD, FACP, SFHM, CCS, CCDS, explores one denial prevention tactic that has proved most effective for his organization.
Protect your office/outpatient E/M claims from front-end denials and post-payment recoupments with the freshest information from Medicare administrative contractors (MAC).
Our experts answer questions about coding for controlled puerperium diabetes and endoscopic procedures as well as provide suggestions for referring to prior encounter information in queries.
It can be especially challenging to thoroughly document rendered services in the emergency department due to the unique needs of the setting. Hamilton Lempert, MD, CEDC, reviews several areas of critical care coding that may trip up clinicians and coders.
Shelley C. Safian, PhD, MAOM/HSM/HI, RHIA , explains ways administration can establish an organizational culture of legal and ethical responsibilities to maintain compliance and honor patients and staff.
CMS’ fiscal year 2025 IPPS proposed rule and fact sheet proposes to upgrade certain codes describing social determinants of health (SDOH) to better capture the effect of housing instability on beneficiaries.
The new ICD-10-PCS code set for fiscal year 2025, which includes 371 new codes, will be effective October 1, 2024. With highlights from Terry Tropin, MSHAI, RHIA, CCS-P , inpatient coders can make sense of each new term before they go into effect.
Sepsis is one of the most prevalent diagnoses necessitating hospital admissions in the United States, and unfortunately, sepsis denials are also prevalent and on the rise. John Williams, RN, BSN, CCDS, clarifies how to ensure all indicators and findings of sepsis are present and valid for each inpatient admission.
Q: A physician documented metabolic encephalopathy on a postoperative patient who was sedated on a vent, but because there were not documented responses while on the vent, I was unable to clinically validate the encephalopathy while the patient was sedated on the vent. How would a coder query this diagnosis for validity?
HIPAA has protocols for when patients’ protected health information can be used for research and marketing. This means you must understand privacy rule limitations and your organization’s policies and procedures before releasing any PHI in these situations. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS finalized many behavioral health requirements related to social determinants of health risk assessments, care management services, and more with the 2024 Medicare Physician Fee Schedule final rule. With all these changes where do providers start?
