Health information management

Read the operative report submitted by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, and consider the CPT and ICD-10-CM codes you would assign. 

This report from HIM Briefings (formerly Medical Records Briefing) looks at trends that may emerge in 2016 and what your organization may want to focus on. 

The Office for Civil Rights recently published its audit protocol for its current privacy and security audits. These protocols give healthcare organizations an inside look at the inspection process. Our sister publication, Briefings on HIPAA, recently published this breakdown of the audit protocols key activities.

Modifiers -25 and -59 remain under scrutiny by Recovery Auditors, CMS, and the OIG. Sarah L Goodman, MBA, CHCAF, CPC-H, CCP, FCS, and Susan E. Garrison, CHC, CHCA, PCS, FCS, CCS-P, CPAR, CPC, CPC-H, answer five questions about correct use of modifiers -25 and -59.

The Centers for Medicare and Medicaid Services (CMS) began the process of clarifying the level of physician supervision for hospital outpatient services in 2008, continuing with further clarifications and regulatory changes through the CY 2012 outpatient prospective payment system (OPPS) final rule. In this white paper, Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc, in Danvers, MA, will explain the current requirements for supervision of hospital outpatient services, as well as the recent clarification in the CY 2012 final rule.

Kathy L. Dorale, RHIA, CCS, CCS-P, Susan E. Garrison, CHCA, CHCAS, CHC, CCS-P, CPC, CPC-H, and Monica Lenahan, CCS, provide analysis and commentary on the results of the 2014 JustCoding Salary Survey in this special report.

This 61-page orthopedic superbill includes ICD-10 and CPT codes and descriptions for a variety of orthopedic services. Roberta Bosank-Cera of Hospitals for Special Surgery, New York, NY, submitted the superbill to the Association of Clinical Documentation Improvement Specialists.

When coding guidelines are murky and open for interpretation, coders can sometimes feel as though they're pinned between a rock and a hard place. Discussing the gray areas of coding during a coding roundtable not only helps relieve this tension, but it also helps to establish policies that ensure consistency and continuity. Use this sample charter to build your own coding roundtable.

Coders frequently struggle with reporting modifier -59 (distinct procedural service) with drug administration services. This excerpt, from JustCoding's Injections and Infusions Coding Handbook, reviewed by Jugna Shah, MPH, covers how to report the modifier for injections and infusions and includes a Q&A for common questions.