Q: What recommendation would you give to the coder when the clinical indicators in the chart do not support sepsis but it’s in the final diagnostic statement?
Some hospitals are incorrectly reporting lymphoma and leukemia MS-DRGs for patients who are admitted and treated for anemia and dehydration, according to the Medicare Quarterly Provider Compliance Newsletter .
Clinical queries serve a definitive purpose when documentation in the medical record is ambiguous, inconsistent, lacking specificity, or contradictory. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, explains why documentation improvement initiatives and heightened coder awareness of the need to query can be an asset or liability.
The majority of respondents in our recent (unscientific) JustCoding poll identified physician documentation as their biggest concern heading into the ICD-10 transition. No one should be surprised by...
ICD-10-CM codes may look completely different, but many of the coding steps remain the same. Betty Hovey, CPC, CPC-H, CPB, CPMA, CPC-I, CPCD; Julia Palmer, MBA, RHIA, CCS ; and Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, FAHIMA, CDIP, AHIMA-approved ICD-10-CM/PCS trainer explain how to code for neoplasms in ICD-10 and which changes to note.
Q: We recently had a situation where a patient had come in to have his port re-assessed. He had been complaining of the port being difficult to access. Preliminary x-ray showed the port accessed, with great blood return. Patient has an allergy to IV contrast, so we just flushed the port, and did not give the contrast. The port remained accessed. How do we code this? Do we use 36598 (contrast injection[s] for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report) with a modifier -52 (reduced services)? The other option is a modifier -73 (discontinued outpatient procedure prior to anesthesia administration) or -74 (discontinued outpatient procedure after anesthesia administration). However we have no documentation regarding anesthesia, and I'm not sure the patient would even get anesthesia for a procedure such as this.
The 2014 IPPS Final Rule was supposed to be implemented with enforcement beginning October 1, but one of its most controversial aspects has seen another delay in enforcement, with major healthcare trade groups seeking more.
Coding for podiatry services requires an extensive understanding of complex anatomy and regulations. Lynn M. Anderanin, CPC, CPC-I, COSC , AAPC Certified ICD-10-CM instructor, AHIMA Approved ICD-10-CM trainer, reviews what steps coders can make to ensure complete documentation for podiatry services that are facing increasing audits.
Mr. Jack O. Lantern underwent some significant surgery at Stitch ‘Em Hospital back on October 16. Dr. Carver removed Jack’s liver, stomach, large intestine, small intestine, appendix, and gall...
Which tasks have you completed on your ICD-10 implementation list? We want to know. Our sister publication , Medical Records Briefing, is conducting a benchmarking survey on ICD-10 implementation,...
Initially, we thought that outpatient coders didn’t have to learn to code in ICD-10-PCS. They would still use CPT® codes to report physician services in the outpatient world. Now it looks like that...
Physicians believe they are providing quality care, which gives them high job satisfaction. However, the problems associated with using electronic health records decreased that satisfaction, according to a recent RAND survey.
A wound is an injury to living tissue caused by a cut, blow, or other external or internal factor. Robert S. Gold, MD , and Gloria Miller, CPC, CPMA , review anatomy and documentation for wounds and explain how to code for wound care in ICD-9 and ICD-10.
The ICD-10 implementation will result in a slowdown at every level of coding. Elaine O’Bleness, MBA, RHIA, CHP, Migdalia Hernandez, RHIT, Kimberly Carr, RHIT, CCS, CDIP, and Rachel Chebeleu, MBA, RHIA, provide suggestions on how to minimize that productivity decline.
Recovery Auditors are data mining for sepsis MS-DRGs and then focusing in on those with a short length of stay. Robert S. Gold, MD, and Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, provide tips for correct sepsis coding to avoid auditor takebacks.
With some major changes in look and form-but generally adhering to existing guidelines-coding for neoplasms serves as a microcosm of the changes providers will face when the transition to ICD-10-CM occurs October 1, 2014.
All pressure ulcers are wounds, but not all wounds are pressure ulcers. A wound is an injury to living tissue caused by a cut, blow, or other external or internal factor. Wounds usually break or cut the skin.
How well could you code in ICD-10 using your current physician documentation? Do your physicians document the specificity and detail coders need to select the correct ICD-10-PCS code? Do your physicians document laterality, which coders will need for many ICD-10-CM codes?
Coders select E/M levels based on criteria developed by their organization. CMS has proposed a significant change to E/M coding-replacing the current 20 E/M levels for new patients, existing patients, and ED visits with three G codes-but that change would only apply to Medicare patients and only to the facility side.
ICD-10-CM implementation is less than a year away and coders should be starting their ICD-10-CM code training if they haven't already. Coders don't need to learn the specific codes right now, but they should be familiar with some of the conventions and guidelines in ICD-10-CM.
Our experts answer questions about followup visits in the ED, skin substitutes, flu vaccines, osteoporosis and fractures in ICD-10-CM, ICD-10-CM external cause code, modifier for discontinued cardioversion, and modifier -25
In this month's issue, we review ICD-10-CM guidelines, illustrate how neoplasm coding will and won't change in ICD-10-CM, identify elements for appropriate ED E/M level selection, and answer your coding questions.
In this month's issue, we explain how coders will report sepsis in ICD-10-CM, go beyond pressure ulcers for coding wound care, review the importance of PEPPER, and reveal how to uncover and correct documentation deficiencies before ICD-10 implementation. Dr. Robert Gold introduces you to SIRS and our coding experts answer your questions.
Coders may find assigning codes for sepsis somewhat easier in ICD-10-CM, but they will still face some challenges. The first of those challenges, and probably the biggest, centers on physician documentation.
If you're not already actively using your hospital's PEPPER (Program for Evaluating Payment Patterns Electronic Report), you're missing out on a lot of valuable data.
Over and over, one gets frustrated that professional coders are told that they are smart and educated and know about anatomy, physiology, and pharmacology, and then the same people turn around and say, "You code what the doctor documented and it's not up to you to question the physician."
Poor Mr. Frank N. Stein, he’s literally falling to pieces. Not to worry, though, Dr. Shelly at the Stich ‘Em Up Hospital will have him back together in no time. Frank’s most obvious problem is that...
Our sister publication , Medical Records Briefing, is conducting a benchmarking survey on ICD-10 implementation, and we would appreciate your input. Please take a few moments to complete this survey...
Coder productivity was a hot topic of conversation during the AHIMA pre-conference in Atlanta October 26-27. We all know coders will be less productive initially after the transition to ICD-10. The...
Greetings from Atlanta! I spent the weekend collecting all kinds of tips and information about ICD-10 during the AHIMA Conference pre-conference sessions. These are just a few of the best tidbits...
The ICD-10-PCS Official Guidelines for Coding and Reporting address four specific circumstances when coders will report multiple procedures. Jennifer Avery, CCS, CPC-H, CPC, CPC-I, and Mark N. Dominesey, MBA, RN, CCDS, CDIP, HIT Pro-CP, explain the guidelines and how they differ from the current ICD-9-CM guidelines.
Approach is the fifth character in the ICD-10-PCS code. Laura Legg, RHIT, CCS, AHIMA-approved ICD-10 CM/PCS trainer , reviews the seven approaches used in ICD-10-PCS.
Coders will use an ICD-10-PCS table to build a code for a hip or knee replacement. As with any procedure, coders must first determine the root operation. Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CPMA, CEMC, CPCD, COBGC, CCS-P, CDIP, and Wanda L. Cidor, guide you through coding for these procedures.
Jacob comes into the Fix ‘Em Up Clinic with a hairy problem—namely too much hair. He’s covered in it, head to tail, I mean toe. He also reports a strange urge to howl at the moon and a severe allergy...
Sitting hunched in front of a computer can be a bad thing. Aside from missing all of the splendid fall foliage, you could also be straining your neck muscles and causing yourself plenty of pain. So...
Mr. Jack O. Lantern is here at Stich ‘Em Up Hospital to have his guts removed. Dr. Carver begins by removing a section of Jack’s skull, then begins to remove Jack’s guts. How would we code this...
Some of the most sweeping changes in OPPS history were proposed in the 2014 rule, including new packaging rules, quality measures, and changes to evaluation and management. Jugna Shah, MPH, and Dave Fee, MBA, look at some of the changes and how they could impact providers.
Packaging still causes confusion amongst healthcare providers and the number of packaged services will greatly expand if CMS finalizes certain parts of the 2014 OPPS proposed rule. Valerie A. Rinkle, MPA, and Kimberly Anderwood Hoy Baker, JD, CPC , discuss what changes could come in 2014 and how to avoid common packaging errors.
New CPT ® codes introduced for 2014 will give healthcare providers new ways to report pain management services and treatments. Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer , reviews some of the codes, including new evaluation and management and Category II codes.
Q: The patient has had a previous bilateral mastectomy and is now coming in for a revision of bilateral areola with a dermal fat graft to the left nipple and excision of excessive skin and subcutaneous tissue from both breasts. This would be CPT ® code 19380 (revision of reconstructed breast) with modifier -50 (bilateral procedure) and 19350-50 (nipple/areola reconstruction) for both procedures. I cannot locate information that tells me if the nipple revision on the reconstructed breast is part of the 19380 or can be separately coded with 19350.
Small and mid-sized hospitals are increasing their ICD-10 training for staff, according to a recent Health Revenue Assurance Associates (HRAA) survey of 200 healthcare professionals. However, many still lag behind CMS’ timeline for dual coding and other implementation aspects.
Welcome to the Middle Ages, when your chance of dying from the plague is around 50-50. The bubonic plague likely wiped out 75-200 million people in Europe in the 14 th century alone. For the...
My brain is fried. Keeping up with all of the mandates and changes in healthcare is exhausting. So is learning the new ICD-10 codes. Maybe I’m just tired because it’s Wednesday. What does ICD-10-CM...
CDI specialists shouldn’t focus on reimbursement, yet the reality is that improved documentation often does lead to higher payments for the hospital. Darice Grzybowski, MA, RHIA, FAHIMA, and Jon Elion, MD, offer tips on how CDI programs can mitigate ethical quandaries and demonstrate best practice.
Although ICD-10-CM resolves some problematic areas of coding, it isn't a panacea. Robert S. Gold, MD reviews how respiratory insufficiency will continue to challenge coders.
Physicians often use different terms interchangeably when documenting sepsis. Robert Gold, MD , and Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, define the different terms and review when to query for additional clarification.
