ICD-10-CM seventh characters can be used to report more than just the episode of care. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, explains different seventh character uses and when to report them.
The 2016 IPPS final rule continues CMS’ plan to shift Medicare payments from volume to quality. Shannon Newell, RHIA, CCS, and James S. Kennedy, MD, CCS, CDIP, analyze the rule and the impact it could have on providers.
Q: In my facility, we are supposed to send an email to our physician advisor (PA) and to administration if a query is not answered within a week. However, this policy doesn’t work well because administration does not do anything with that information, and the PA doesn’t have time to review unanswered queries. Do you have any suggestions concerning when to let a query go unanswered?
CMS has released a transcript and recording of its August 27 MLN Connects Call featuring ICD-10 coding guidance and the results of CMS’ final round of end-to-end testing.
Six ICD-10-PCS root operations require a device, including Revision, Replacement, and Removal. Gretchen Young-Charles, RHIA, and Anita Rapier, RHIT, CCS, review how to differentiate these root operations and report associated devices.
Robert S. Gold, MD, discusses educational opportunities for sequencing viral gastroenteritis, coding past medical conditions, and reporting neonatal codes.
ICD-10 implementation will arrive very soon, and many facilities are putting the final touches on their preparations. In the rush to complete coding education, documentation improvement, and system updates, HIM managers may not have looked at looming MS-DRG shifts.
The 2016 OPPS proposed rule released July 2 is deceptively short, but packs a punch. CMS is proposing the most massive APC reconfiguration and consolidation of APC groups since the beginning of OPPS, says Jugna Shah, MPH, president and founder of Nimitt Consulting, based in Washington, D.C., and Spicer, Minnesota.
OPPS costs rose approximately $1 billion more than expected in 2014 due to a CMS overestimation of the impact of laboratory packaging changes, according to the 2016 OPPS proposed rule. As a result, CMS proposes a 2% reduction to the 2016 conversion factor. CMS also proposes to expand laboratory packaging from date of service to the claim level.
In this month's issue, we review the quality and coding changes finalized in the 2016 IPPS final rule and explain how to identify MS-DRG shifts in ICD-10-PCS. Robert S. Gold discusses sequencing viral gastroenteritis, coding past medical conditions, and reporting neonatal codes
The only difference between ICD-10-PCS root operations Excision and Resection is the amount of the body part removed. Jennifer Avery, CCS, COC, CPC, CPC-I, Anita Rapier, RHIT, CCS, and Cheree Lueck, BSN, RN, provide tips for determining the correct root operation.
In ICD-10-CM, to tell the patient’s whole story, coders need to report external cause codes. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, explains the benefits of these codes and how to report them.
ICD-10-PCS will completely change the way coders report inpatient procedures. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Lynn Kuehn, MS, RHIA, CCS-P, FAHIMA, reveal potential trouble spots for the new coding system.
Every once in a while, another facility will send us a case to review and help them code. Here at the Fix ‘Em Up Clinic, we are happy to share our knowledge as we prepare for October 1. In that...
The 2016 OPPS proposed rule introduces APC restructuring, new comprehensive APCs, and many other potential changes for next year. Jugna Shah, MPH, and Debbie Mackaman, RHIA, CPCO, CCDS, review the proposals and what they could mean for providers.
CMS is proposing a new status indicator to be assigned to laboratory tests so when the tests are the only service on a claim, CMS will pay for them separately under the Clinical Laboratory Fee Schedule without providers having to do anything additional from a reporting perspective.
ICD-10 implementation is almost here, but coders are still facing resistance from physicians. W. Jeff Terry, MD, highlights ICD-10 challenges from the physician perspective, while Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, responds from a coder’s point of view.
The expanded code set available in ICD-10-CM will give providers the chance to better tell the story of each patient’s care. Glenn Krauss , RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM, explains how coders can assist physicians in telling that story .
Q: I have a question regarding facility coding for evaluation and management (E/M) levels, not for an ED physician, but for facility-level nursing in the ED. If a specialist is called to evaluate or consult on a patient, the nursing intervention is what the facility-level criteria is based on. For example, a patient has difficulty walking, a nurse assists the patient to get an x-ray, takes vitals, does an initial assessment, then provides discharge instructions of moderate complexity. I would code this scenario as a level 3.
We’re 43 (calendar) days from ICD-10 implementation. We’ve only got 31 working days until October 1. If you are all set for ICD-10, you’re probably fine tuning your coding and documentation, maybe...
Kids will soon be heading back to school here in Anytown, which also means the sports teams are holding preseason camps. And some of our local players practice a little too hard. Take Shaun, for...
Q: If the physician documents “concerning for,” “considering,” “cannot be ruled out,” or “cannot be excluded” for a diagnosis, is that considered an uncertain diagnosis? Can those terms be coded if the patient is being worked up? Are the terms “concerning for” and “considering” equal to the uncertain diagnosis terms “yet to be ruled out”?
With Recovery Auditor audits on hold, hospitals may have experienced a decrease in the number of audits that must be addressed. Cathie Wilde, RHIA, CCS, and Kim Carr, RHIT, CCS, CDIP, CCDS, explain why organizations still need to be able to justify code assignment.
Drainage procedures can be therapeutic in nature or diagnostic, such as when a physician removes a fluid or gas for biopsy. A nita Rapier, RHIT, CCS, Nelly Leon-Chisen, RHIA, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS , highlight the differences in coding diagnostic and therapeutic thoracocentesis and lumbar tap procedures in ICD-10-PCS.
Medical record audits provide opportunities to educate coders, physicians, and/or clinical documentation improvement specialists. Robert S. Gold, MD, offers tidbits about volume overload and heart failure from recent reviews he’s done.
The absolute best ICD-10 education is completely free, assuming you have an Internet connection. It will tell you everything you need to know about coding in ICD-10. What is this magical, mystical...
Armadillos apparently pose more hazards to your health than just passing on leprosy. A Texas man recently tried to shoot an armadillo three times and ended up being hit by his own bullet . He claims...
Hospitals did not get any ICD-10 relief as part of CMS’ accord with the AMA regarding a specificity grace period . However, they might not need much help, according to the latest Workgroup for...
Coders may need to review the anatomy of the gastrointestinal system and disease processes for gallstones, hemorrhoids, and ulcerative colitis to choose the most specific ICD-10-CM code. Jaci Johnson Kipreos, CPC, CPMA, CEMC, COC, CPC-I, and Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, explain aspects of anatomy and what coders will need to look for in the documentation.
Q: We had a patient come into our ED with a severe head injury. To protect his airway, we intubated the patient. Can we report an emergency endotracheal intubation (CPT ® code 31500) and CPR (92950) together if only bagging happens and no chest compressions?
CMS has released a document to clarify questions providers raised about its recent guidance on ICD-10-CM, including answers on how the agency is defining a family of codes.
CMS has repeatedly tweaked its logic regarding comprehensive APCs since inception. Dave Fee, MBA, reviews the latest changes regarding complexity adjustments, as well as new and deleted codes.
Organizations have their hands full with ICD-10-CM implementation finally on the horizon. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, and AHIMA-approved ICD-10-CM/PCS trainer, examines how coding departments can clean up their processes now so they are ready for the new code set.
Bacteria are everywhere. Literally. And you can’t see them or feel them. In fact, trillions of them are living on your skin right now. So not all bacteria are bad. Some, though, can do nasty things...
ICD-10-PCS root operations Excision and Resection differ only in how much of a body part is removed. Review these situations to clarify which root operation to report.
Ask a physician why he or she documents in the medical record and you'll get a variety of answers. Some physicians will say they document because the medical records people hound them for the information, or they do it so they get paid. They may also say they do it to complete the medical record.
We're less than four months away from the implementation of ICD-10-CM/PCS, and the AHA Coding Clinic for ICD-10-CM/PCS is rolling right along with advice for the new code set.
Physician groups have led much of the resistance against ICD-10 implementation. At its June Delegates meeting, the AMA approved a resolution from W. Jeff Terry, MD, for a two-year grace period to protect physicians from errors and mistakes related to the code set. Terry also authored an AMA resolution to delay ICD-10 in November 2011, which led to postponing implementation until October 1, 2014.
It's great, identifying opportunities to teach. Whenever I do medical record audits, I always look for chances to educate coders, physicians, and/or CDI specialists about areas of misunderstanding by coding professionals or elements of patient experience that require specific documentation for proper code assignment.
Although CMS did not propose any changes to the 2-midnight rule in the fiscal year 2016 IPPS proposed rule, it signaled its intention to address short stays in the calendar year (CY) 2016 OPPS proposed rule. CMS followed through by introducing several proposed changes to the 2-midnight rule.
In this month's issue, we speak with physicians about queries in ICD-10-PCS and look at some specialty-specific procedures that may require queries. We offer tips on how to differentiate between ICD-10-PCS root operations Excision and Resection and review the changes CMS proposed to the 2-midnight rule. Robert S. Gold, MD, reveals how to use audit findings to your advantage.
