CMS and Medicare Administrative Contractors are aware of certain issues regarding National Coverage Determinations and Local Coverage Determinations related to ICD-10 and working to resolve them as soon as possible, according to CMS.
CMS does not require ordering providers to rewrite orders prior to ICD-10 implementation with appropriate diagnosis codes for laboratory, radiology, and other services, including durable medical equipment, prosthetics, orthotics, and supplies, according to a new FAQ.
Sherry Corsello, RHIT, CPC, writes about how to ensure consistency and reliability of records in ICD-10 and what providers can do with the more accurate data the code set will give them.
Garry L. Huff, MD, CCS, CCDS, and Brandy Kline, RHIA, CCS, CCS-P, CCDS, provide an overview ofkey information providers need to document for coders to assign proper codes for chronic kidney disease and acute kidney injury.
Coders need to understand the clinical presentation of sepsis to report it accurately. Robert S. Gold, MD, and Gloryanne Bryant, RHIA, RHIT, CCS, CDIP, CCDS, review how to identify sepsis and tips for coding it in ICD-10-CM.
Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV) site used have to come from the physician in the progress note or can this particular information be extrapolated from nursing notes, orders, etc.? As far as I can tell, a blood transfusion is usually administered to whatever peripheral IV line/site is available, unless otherwise contraindicated or instructed differently by a specific physician order.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, answers questions from coders about OB diagnoses and procedures, including what’s bundled in the global package and how to report multiple births.
Extensive changes in ICD-10-CM terminology and codes for cardiovascular diseases often frustrate coders, says Cindy Basham, MHA, MSCCS, BSN, CCS, CPC . She provides an overview of the changes and notes what must be documented so coders can select the appropriate code.
Providers need to be careful when reporting multiple services with status indicator J1 on the same claim. Dave Fee, MBA, reviews potential concerns with reporting multiple comprehensive APCs as well as new codes and APCs introduced in the October 2015 I/OCE update.
Q: We are an independent outpatient end-stage renal disease clinic. When we administer a blood transfusion (we do not bill for the blood) can we bill HCPCS code A4750 (blood tubing, arterial or venous, for hemodialysis, each) for the tubing used in the procedure and also A4913 (miscellaneous dialysis supplies, not otherwise specified) for miscellaneous supplies pertaining to administering the blood?
CMS introduced several new HCPCS codes and added comprehensive APCs (C-APC), including one for observation, in the 2016 OPPS final rule, released October 30.
Jillian Harrington, MHA, CCS, CCS-P, CPC, CPC-P, CPC-I, MHP, reviews the components in operative reports coders will need to find in order to report ICD-10-PCS codes for spinal fusions.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about the section added to ICD-10-PCS for 2016 for reporting new technology procedures.
ICD-10 may be a new system with thousands of additional codes compared to ICD-9-CM, but that doesn’t mean it can still accurately report every clinical scenario. Robert S. Gold, MD, identifies conditions that aren’t necessarily represented by the codes available.
Q: Is there guidance on reviewing a record, such as an operative note, that has not been signed by a physician? I am at a facility that allows coding from unsigned transcriptions. I was always told that the information needs to be confirmed by a signature as valid before including that information in the review worksheet. Do you have any recommendations for this?
CMS finalized its proposals regarding the 2-midnight rule in the 2016 OPPS final rule, including moving responsibility for enforcement and education of the rule from Recovery Auditors to Quality Improvement Organizations (QIO). This latter change occurred October 1, 2015.
I have been musing recently about things I've written for this journal over the past years. Hard to believe I've been doing monthly educational articles regarding the clinical aspects of coding since about 2002.
After years of delays, industry and legislative pushback, and millions spent on technology upgrades and education, ICD-10 is finally here. Even though the fundamental process of coding and billing claims has not changed, providers will still need to pay close attention to their processes to keep the revenue cycle going and reduce denials.
After several delays, ICD-10 implementation is finally upon us. The healthcare industry has spent years planning, training, and testing?and now the moment we have all been waiting for has arrived. But don't breathe a sigh of relief just yet.
