Forms

The attached is a commonly used occurrence reporting form used by coding professionals to report documented issues requiring risk management’s attention. This form was excerpted from JustCoding’s Practical Guide to Coding Management, Second Edition.

Modifier -25 indicates a "significant, separately identifiable E/M service." Incorporate the tips below and click the "Download file" link above to access a modifier -25 decision tree.

The following chart illustrates the case of a patient admitted for pneumonia with the additional diagnosis of heart failure. In this case, the principal diagnosis is J18.9, pneumonia unspecified, listed under DRG 193, simple pneumonia and pleurisy with MCC. However, the documentation in this instance does not contain enough clinical information to support the heart failure as an MCC. In order to do that, the case requires more clarification of the diagnosis of heart failure and must be queried.

This crossword puzzle includes terminology for respiratory conditions. 

Practice your knowledge of debridement terms using this word search. 

The attached is a query template that inpatient coders can use to clarify sepsis documentation. 

The following decision tree addresses the mistakes that auditors for Medicare administrative contractors (MAC) and investigators are finding. Share it with providers and billing staff to help them recognize when they can — and cannot — bill a visit incident-to a physician.

Case Study - Removal of Venous Access Port

PREOPERATIVE DIAGNOSIS: Acute lymphocytic leukemia in remission.

POSTOPERATIVE DIAGNOSIS: Acute lymphocytic leukemia in remission.

OPERATION PERFORMED: Removal of tunneled venous port.

ANESTHESIA: General.

INDICATIONS: This 19-year-old patient presented with ALL and had a tunneled venous access port placed at that time. Patient has subsequently undergone chemotherapy and is now off therapy, and no longer needs a venous port.