Physician office coders are likely familiar with coding for x-ray procedures, but may not have much experience coding ultrasound. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, and ICD-10-CM/PCS trainer, reviews how ultrasound procedure codes are categorized and offers tips on reporting them in office settings.
Q: I am a coder in a hospital outpatient setting. Our physicians document drug use in social history. For example, marijuana use is documented as just "marijuana use" without any further information regarding a pattern of use or abuse. Based on that information, can I report ICD-9-CM code 305.20 (cannabis abuse, unspecified)? How would this be reported in ICD-10-CM?
The 2015 CPT ® Manual included big changes to drug test reporting. Denise Williams, RN, CPC-H, AHIMA-approved ICD-10-CM/PCS trainer and AHIMA ICD-10 ambassador, and Steven Espinosa, CCS, AHIMA-approved ICD-10-CM/PCS trainer, explain the changes and how they will impact documentation and coding.
Remember those friends and family cell phone plans where you didn’t use minutes if you called people in your circle? You had to pick who you wanted in your group and they had to pick you. It was very...
CMS and the American Medical Association (AMA) may have made peace regarding ICD-10, but it seems some members of Congress didn’t get the memo. Reps. Marsha Blackburn, R-Tenn., and Tom E. Price, R-Ga...
The optical system is the most complex organ system of the human body and is subject to specific disease processes. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer explains how to code some common eye diseases and treatments in ICD-10.
Q: Can “in the setting of”' be interpreted as “due to” in ICD-10-CM? For example, the physician documented that the patient has a urinary tract infection in the setting of a urinary catheter.
CMS announced a new incentive program designed to reduce complications from joint replacement surgery. The new proposed Comprehensive Care for Joint Replacement will require bundling of reimbursement for hip and knee surgeries, with profits tied closely to costs and quality metrics.
The AHA’s Coding Clinic for ICD-10 continues to provide updates and guidance for a variety of inpatient procedures, both routine and not so routine. J ames S. Kennedy, MD, CCS, CDIP, Anita Rapier, RHIT, CCS, and Sharme Brodie, RN, CCDS, highlight some important advice from Coding Clinic.
ICD-10-PCS root operations Drainage, Extirpation, and Fragmentation involve removing material from the body, but in different ways. A nita Rapier, RHIT, CCS, Kristi Stanton, RHIT, CCS, CPC, and James Fee, MD, CCS, CCDS, offer tips for distinguishing between the root operations.
Alas, poor urosepsis. I knew him, Horatio, a condition of infinite vagueness. And thankfully, one ICD-10-CM is putting out to pasture. Now, if only the physicians would get on board. Physicians...
People do some strange things on vacation. I mean, really, really strange things. Take Mike, for example. Mike just returned from his European vacation and has come into the Fix ‘Em Up Clinic for a...
Q: When the surgeon documents excision of a complex pilonidal cyst with rhomboid flap closure, is the flap closure coded separately or is it included in CPT ® code 11772 (excision of pilonidal cyst or sinus; complicated)?
Despite no recent changes from CMS, many providers still struggle with when to report modifier -25 (significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service) . Jugna Shah, MPH, explains how providers can review claims to determine if they are using the modifier correctly.
Since CMS introduced comprehensive APCs in January, the agency has continued to tweak the logic and codes included in the process. Dave Fee, MBA, and Judith L. Kares, JD, describe those changes in CMS’ April quarterly updates and review code and edit updates.
Betty Hovey, CPC, COC, CPB, CPMA, CPC-I, CPCD, and Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, review anatomy details of the heart and how to report ICD-10-CM codes for atherosclerosis and conduction disorders.
CMS continues to move toward increased packaging with its policies in the 2016 OPPS proposed rule released July 2, with additional comprehensive APCs (C-APC) and extensive APC reconfigurations.
After a vigorous, last-ditch push by the AMA for a two-year transition period after implementation to protect physicians from all ICD-CM coding errors and mistakes, CMS and AMA made a joint...
The Fourth of July is in the books for another year and once again, we saw an interesting assortment of patients in the Fix ‘Em Up Clinic over the weekend. Let’s take a look at some of the more...
We’re officially three months (okay, 91 days) away from ICD-10 implementation, so you need to give your surgeons a quick introduction to ICD-10-PCS. Do NOT try to teach them to code. That’s not the...
Respiratory failure, whether acute or chronic and whether following surgery or not, is one diagnosis that is always an easy target for those who abuse the documentation and assignment of ICD codes.
In this month’s issue, we review some of Coding Clinic’s advice for ICD-10, examine how clinical indicators can help coding for acute kidney injury, and discuss inclusions, exclusions, and coding and documentation vulnerabilities for PSI 12. Robert S. Gold, MD, explains why respiratory failure isn’t always respiratory failure.
Most coding professionals have heard modifier -59 (distinct procedural service) referred to as a modifier of last resort and to be cautious in using this modifier.
Physicians often use the terms acute renal failure (ARF) and acute kidney injury (AKI) interchangeably to describe an abrupt decrease in kidney function that is reversible within three months of loss of function.
In an effort to accommodate the latest advances in technology and make the code set easier to modify for future technological changes, the AMA extensively overhauled codes for reporting drug testing in the 2015 CPT ® Manual.
PSI 12 evaluates the hospital's risk-adjusted rate of perioperative deep vein thrombosis (DVT) and/or pulmonary embolism (PE) in surgical discharges for patients 18 years and older. Performance for PSI 12 contributes 25.8% of the PSI 90 composite score under the Hospital-Acquired Condition Reduction Program.
In an effort to accommodate the latest advances in technology and make the code set easier to modify for future technological changes, the AMA extensively overhauled codes for reporting drug testing in the 2015 CPT® Manual.
With fewer than 100 days until ICD-10-CM/PCS implementation, plenty of questions still remain about ICD-10-PCS coding. The AHA's Coding Clinic for ICD-10 continues to provide updates and guidance for a variety of inpatient procedures, both routine and not so routine. We examine some of that guidance in this article.
Lately I've received a lot of questions from hospitals about how to determine when and if it's appropriate to report an E/M visit code on the same date of service as a scheduled procedure.
Jurassic World is ruling the box office, so I thought I would use another blast from the past for the blog. Archeologists in Peru recently uncovered the skeleton of a teenage girl in a historic...
Richard came in to see Dr. Guts complaining of severe abdominal pain, nausea, vomiting, and blood in his stool. Dr. Guts sends Richard for a battery of tests and discovers Richard suffers from a...
How ready are you for ICD-10? The answer might depend on the type and size of your organization. Eighty-five percent of hospitals reported training staff on ICD-10, according to a recent eHealth...
Multiple surveys have shown that physician practices are lagging behind in preparation for ICD-10. CMS recently released a Quick Start Guide that outlines five steps healthcare professionals should...
Cardiac conditions are some of the most common diagnoses seen in hospitals. Betty Hovey, CPC, COC, CPB, CPMA, CPC-I, CPCD, and Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, review coding conventions and documentation details for reporting heart failure and angina in ICD-10-CM.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, explains how to identify anemia in documentation for OB/GYN patients and which ICD-9-CM and ICD-10-CM should be reported.
Q: Should modifiers for laterality be used for CPT ® code 31624 (bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage)?
Many organizations still lag in ICD-10 implementation, but it's not too late to prepare. Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS; Jean S. Clark, RHIA, CSHA; and Caroline Piselli, MBA, RN, FACHE, detail the steps organizations should take in order to be ready by October 1.
A survey conducted in May and June 2015 found providers have completed many steps toward ICD-10 implementation, but lag behind in testing and expect to continue managing the impact after the deadline.
The American Medical Association (AMA) is pushing for a two-year safe harbor for physicians so the doctors won’t be penalized for “errors, mistakes, and malfunctions relating to the transition.” That...
Mary decided to take advantage of a break in the rainy weather to head out and do some bird watching. The birds, however, were in no mood to be watched. Mary first came upon a warbler nest with four...
Q: In ICD-9-CM, sprains and strains fall under the same codes. Will that also be the case in ICD-10-CM or are we going to report these injuries separately?
Sharme Brodie, RN, CCDS , highlights guidance on ICD-10-PCS root operations and seventh characters for ICD-10-CM from the latest issue of Coding Clinic .
ICD-10-PCS does not include unspecified options so coders will need information for each of the seventh characters in the code. Cheryl Ericson, MS, RN, CCDS, CDIP, and Lynn Salois, RHIT, CCS, CDIP, review some of the areas where a surgical query might be needed.
Coding Clinic serves as the Supreme Court in interpreting ICD?9?CM or ICD?10?CM/PCS and their guidelines. James S. Kennedy, MD, CCS, CDIP, Kyra Brown, RHIA, CCS, and Nelly Leon-Chisen, RHIA, discuss the best ways to use this additional guidance.
Coders will find 50 new codes in ICD-10-PCS for 2016, according to the summary of changes posted by CMS . CMS also introduced a new section for ICD-10-PCS, X (new technology). In addition, guidelines B3.11b, B3.4a, B3.2b, and B4.1b were revised in response to public comment.
Sometimes the logic of the American Medical Association (AMA) escapes me. Okay, most of the time, I have no idea what the people at the AMA are thinking. Take the organization’s continuing crusade to...
Rep. Gary Palmer, R-Alabama, doesn't want providers penalized for ICD-10 "errors, mistakes, and malfunctions relating to the transition" for two years after implementation. Unfortunately, it doesn't...
The Alabama state Senate passed a Joint Resolution urging Congress to delay the October 1, 2015 ICD-10 implementation. In and of itself, the resolution means very little. States cannot override the...
Shelley C. Safian, PhD, RHIA, CCS-P, CPC-H, CPC-I, writes aboutwhat additional details coders will need to find in documentation to report pneumonia to the highest degree of specificity in ICD-10-CM and how to report it as a manifestation.
