Sequela, or late effect, is the remaining or lasting condition produced after the acute stage of a condition or injury has ended. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, reviews the correct way to code for sequelae in ICD-9-CM and ICD-10-CM.
For anyone who has not yet started ICD-10 training, CMS posted a transcript, audio file, and slide presentation from the June 4 More ICD-10 Basics MLN Provider call on its website.
Q: A few days into the patient’s stay, an order for a Foley catheter was placed for incontinence and around the same time the physician documented a urinary tract infection (UTI). Would it be appropriate to query the physician regarding the relationship of the UTI to the Foley? Our infection control department caught this but we did not. I am concerned about this for two reasons; first, I worry about writing a leading query and second, whether the UTI could be considered a hospital-acquired condition (HAC) if additional documentation isn’t provided.
Dodge ball is not a game for wimps or the uncoordinated. Even master ball dodgers can end up in the Fix ‘Em Up Clinic. Steve engaged in a spirited game of dodge ball over the weekend, which resulted...
What do you get when you combine a full moon and Friday the 13th? Some really odd injuries at the Fix ‘Em Up Clinic. Fortunately, we here at the clinic suffer from neither paraskevidekatriaphobia (...
I recently spoke with Barbara Hinkle-Azzara, RHIA , vice president of HIM operations for HRS Coding in Baltimore about preparing for ICD-10 and, more specifically, about the anticipated MS-DRG...
Guidance for coding OB delivery lacerations sometimes differs between the CPT ® Manual and the American Congress of Obstetricians and Gynecologists. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , explains the difference in guidance and documentation necessary to report tears to the proper degree.
Q: If the clinical impression is physical assault, vomiting, blunt injury to abdomen, and head injury with loss of consciousness, can I code the history of hypertension, diabetes mellitus, headache, bipolar disorder, and depression?
On July 1, CMS will implement a variety of changes to current supervision requirements as recommended by the Hospital Outpatient Payment Panel. Debbie Mackaman, RHIA, CHCO , reviews the panel's recommendations, and which CMS plans to accept or reject.
A patient comes into the ED following an automobile accident. The physician documents that the patient has an open, displaced fracture of the lateral condyle of the right tibia. The physician also...
We all know that ICD-10 codes will require more complete documentation. We’ve been telling physicians that, but maybe we’re not explaining it well or correctly. What makes documentation better? It’s...
Both knee and shoulder replacement procedures include devices and fall under the ICD-10-PCS root operation Replacement (R). Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, and Nena Scott, MSEd, RHIA, CCS, CCS-P , review the definition of a device in ICD-10-PCS and review how to code for shoulder and knee replacements.
Both knee and shoulder replacement procedures include devices and fall under the ICD-10-PCS root operation Replacement (R). Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, and Nena Scott, MSEd, RHIA, CCS, CCS-P , review the definition of a device in ICD-10-PCS and review how to code for shoulder and knee replacements.
ICD-10-PCS root operations Occlusion, Restriction, and Dilation involve changing the diameter of a tubular body part. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Angie Comfort, RHIT, CDIP, CCS, review the definitions of these root operations and examine when they should be used.
CMS made relatively few changes in the April quarterly I/OCE update, introducing four new APCs, deleting one, and reclassifying several skin substitute codes.
In this month’s issue, we review the changes CMS proposed in the 2015 IPPS proposed rule. Shannon E. McCall explains why you should view the latest ICD-10 implementation delay with optimism instead of skepticism. Dr. Robert Gold discusses wound care coding in ICD-10.
