As Lucile Packard Children's Hospital in Palo Alto, Calif., implemented its EHR, the dreaded problem of copy and paste documentation began to rear its ugly head.
Physicians and other providers practice in many different areas within a hospital. To accurately code physician and provider services, coders must know and understand the place of service (POS) codes.
In November 2011, the FDA approved transcatheter aortic valve replacement (TAVR) to treat aortic valve stenosis for those patients who are not candidates for traditional open-heart surgery. This procedure is also referred to as a transcatheter aortic valve implantation (TAVI).
In this month's issue, we review the overhaul of CPT's psychiatry section and new codes for cardiology procedures, examine CPT's new provider neutrality language, and examine place of service codes.
One of the major changes to the 2013 CPT Manual is the replacement of the term "physician" with "physician or other qualified healthcare professional" (QHP) in a wide range of codes.
The ICD-9-CM guidelines state that it's unusual for two or more diagnoses to meet the definition of principal diagnosis. However, coders know this isn't exactly true, as the scenario tends to occur frequently.
Underdosing is a new coding concept in ICD-10-CM and it has its own column in the table of drugs. Underdosing can be accidental (patient forgot to take the medication) or intentional (patient chose...
The FY 2013 Office of Inspector General (OIG) Work Plan includes plenty of new additions that might interest inpatient hospitals. Sara Kay Wheeler, Kimberly Anderwood Hoy, JD, CPC, Monica Lenahan, CCS, and William E. Haik, MD, FCCP, CDIP, review those new additions and offer tips for dealing with OIG scrutiny.
Coders should avoid reporting signs and symptoms as the principal diagnosis when possible. However, that’s not always possible. William E. Haik, MD, FCCP, CDIP, reviews the ICD-9-CM principal diagnosis selection guidelines and when coders should report signs and symptoms as the principal diagnosis.
If you’re curious about whether something you’ve heard or read about the Recovery Auditor program is true, be sure to check out new information published on the CMS Web site. The agency released a document that addresses 14 common myths about the program.
Electronic health records (EHR) provide opportunities for more efficient and effective care, yet they also provide coding and documentation challenges. Jill M. Young, CPC, CEDC, CIMC, explains what coders need to be wary of when coding from an EHR.
Q: One of our orthopedic surgeons started to perform spinal fusions percutaneously. CPT ® provides instruction on how to code this procedure; however, these are inpatient surgeries, so we need an ICD-9-CM code. We’re leaning toward code 81.00 (spinal fusion unspecified). Do you think this is the correct code?
Now is the best time to consider the clinical documentation initiatives you need to implement in 2013. The preparation for ICD-10 has documentation needs first and foremost on everyone’s mind. Start...
ICD-10-PCS is vastly different from the ICD-9-CM procedure codes inpatient coders currently use. By now, you probably know that ICD-10-PCS codes must be seven characters in length. The letters I and...
On January 9, the American Medical Association sent out a notification of errata in the 2014 CPT ® Manual . The AMA followed with a January 16 correction saying the errata file is for the 2013 CPT Manual .
ICD-10-CM includes separate chapters for diseases of the eye and diseases of the ear, a change from ICD-9-CM, where both diseases are included in the nervous system codes. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, explains how the ICD-10-CM codes for diseases of the eyes and ears are similar to and different from ICD-9-CM codes.
Deborah Grider, CPC, CPC-I, CPC-H, CPC-P, CPMA, CEMC, COBGC, CPCD, CCS-P, CDIP, senior manager at Blue and Company in Indianapolis, an industry expert on ICD-10, provides preparation tips and action steps for ICD-10 implementation.
The use of dual coding is frequently discussed and debated as a way to prepare for the transition to ICD-10. Donna Smith, RHIA, Thea Campbell, MBA, RHIA, Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS, and Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, evaluate the pros and cons of dual coding.
I am back to my ICD-10 blog following a long illness. It is great to be back! Why is it that a date ending in 2013 seems so much closer to October 2014? Others must feel this way because there seems...
Anytown got hit with some significant snowfall, which lead to some interesting injuries at the Fix ‘Em Up Clinic. Dave came in complaining of back pain after spending two hours shoveling his driveway...
Cold and flu season is in full swing, so I thought it might be a good time to look at coding for influencza in ICD-10-CM. If you look up influenza in the ICD-9-CM index, you might think we currently...
National Government Services, under contract with CMS, will host a series of listening sessions about lessons learned from the Version 5010 upgrade to prepare providers, vendors, and payers for the transition to ICD-10-CM/PCS.
Q: I’ve heard that queries differ between critical access and short-term acute care hospital settings. Is this true, and if so, where can I find more information?
Leading queries are frequently a topic of discussion among coding and clinical documentation improvement professionals. Glenn Krauss, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, explains how to determine what constitutes a leading query and how to craft compliant queries.
Physicians, especially ED physicians, need to start paying attention to how their documentation affects the facility. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, and Bernadette Larson, CPMA, discuss how documentation in the ED affects medical necessity and inpatient coding.
MLN Matters ® article SE1236, which discusses documenting medical necessity for major joint replacements, may be aimed at physicians, but Glenn Krauss, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, and Lynn Marlow, BS, RHIT, CCS, explain how it also applies to hospitals and coders.
A sequela is the residual effect (condition produced) after the acute phase of an illness or injury ends. ICD-10-CM includes codes specifically designed to report sequela, such as I69.953 (hemiplegia...
Being a Jedi knight is hard work. And it’s dangerous, especially when your father is out to kill you and your friend gets encased in carbonite. Intrepid coders that we are, we will brave the frozen...
Coders will find plenty of changes throughout the musculoskeletal, respiratory, and cardiac sections of the CPT® Manual for 2013, as well as guidelines changes, deletions, and editorial revisions. Andrea Clark, RHIA, CCS, CPC-H, Georgeann Edford, RN, MBA, CCS-P, and Marie Mindeman walk through some of the major changes for 2013.
Q: How should we bill for the physician in the following situation? A patient who has end-stage renal disease (ESRD) comes into a hospital’s emergency department (ED) with an emergent condition (dialysis access clotted or chest pain that is ruled out), but misses his or her dialysis treatment. Part of the treatment is dialysis performed in the ED or as an outpatient. The hospital bills G0257 (unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility) as per CY 2003 OPPS Final Rule guidelines and Pub 100-04, Chapter 4, section 200.2
The American Medical Association completely overhauled the CPT ® Manual’s psychiatry subsection for 2013. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, explains the new codes and guidelines associated with psychiatric services.
CMS announced changes to reporting therapy services—the biggest operational change for 2013—in the Medicare Physician Fee Schedule final rule instead of the OPPS final rule. Jugna Shah, MPH, and Valerie Rinkle, MPA, explain the changes to therapy reporting and molecular pathology coding.
Coding for stent placement procedures will look very different in 2013. The American Medical Association deleted the two CPT ® codes used to report nondrug-eluting intracoronary stent placement procedures.
So far, we’ve covered three different ICD-10-PCS guidelines for multiple procedures. We’ve looked at how to report multiple procedures involving: Same root operation, different body parts as defined...
Happy 2013! We survived the Mayan apocalypse and received a one-year extension on ICD-10 implementation (which according to some people is more of an apocalyptic event than 12-21-12). Where do your...
In this month's issue, we review the major changes to OPPS for 2013, discuss the potential impact of CMS' packaging clarification, examine therapy, molecular pathology changes, offer suggestions on how to begin teaching providers to speak ICD-10, and answer your coding questions.
Providers and coders seem to speak two different languages-clinical and coding. Providers already have issues parsing ICD-9-CM "coder speak," so how can you get them to understand ICD-10?
Upon quick glance, the FY 2013 ICD-10-CM Official Guidelines for Coding and Reporting probably look very familiar to coders. They're comparable in length to the ICD-9-CM guidelines. They also follow the same format.
Hospitals earned a big win with drug payments this year in the 2013 OPPS final rule, released November 1. CMS decided to finalize its proposal to follow the statute and reimburse facilities at the average sales price (ASP) plus 6%.
After a six-month delay, the Recovery Auditor prepayment review demonstration program began in August 2012. The program continues through August 2015, at which point CMS will determine the potential for a national rollout.
The biggest operational change for outpatient facilities for 2013 does not appear in the 2013 OPPS final rule. Instead, CMS announced changes to reporting therapy services in the 2013 Medicare Physician Fee Schedule (MPFS) final rule.
After a six-month delay, the Recovery Auditor prepayment review demonstration program began in August 2012. The program continues through August 2015, at which point CMS will determine the potential for a national rollout.
As part of the 2013 OPPS final rule, CMS finalized a clarification to 42 CFR 419.2(b) that could cause confusion in the future if hospitals are audited by third-party payers or by Medicare contractors who do not fully understand the intent of the language or how CMS develops payment rates, says Jugna Shah, MPH, president of Nimitt Consulting based in Washington, D.C.
