Psychoactive Substance Use – Revisited

Cathie Wilde, RHIA, CCS - Director, Coding Services Medical Coding Leave a Comment

Mental, behavioral and neurodevelopment disorders located in Chapter 5 of the ICD-10-CM Coding Manual were first addressed in the August 10, 2021, MRA Blog (https://www.mrahis.com/blog/chapter-5-coding). Here, we will be specifically discussing the mental and behavioral disorders related to psychoactive substance use which are included in Chapter 5.   Alcohol and...

pTX and pNX Removed from Cancer Staging Protocols

Suzanne Neve, RHIA, CTR - Director, Cancer Registry Cancer Registry Leave a Comment

After extensive discussion with the American Joint Committee on Cancer (AJCC) the College of American Pathologists (CAP) announced in June, 2021 that use of pTX and pNX will be removed from the cancer staging protocols and no longer listed as an option in printed or electronic cancer staging protocols.   The group’s consensus was “…that of the AJCC as the standard-setting...

MTHFR and Its Role in Homocysteine

C. Matheson, RHIA, CCS HIM Leave a Comment

MTHFR. Sounds almost rude, doesn’t it? However, it is NOT something for which your mother would threaten to wash your mouth out with soap, I promise. MTHFR stands for methylenetetrahydrofolate reductase – so obviously, using the abbreviation is easier than saying that mouthful every time. What, exactly, IS MTHFR? It’s a genetic mutation affecting approximately 30% of the...

Capturing and Integrating Social Determinants of Health for EHR

Heather Chartier, MS, RHIA, CCA EMR Leave a Comment

Social Determinants of Health: Everyone's Challenge and Benefit Concurrent with a refined focus on Social Determinants of Health, the benefit of using electronic health records for managing the health of populations as well as individuals has garnered attention. With the implementation of provisions of the ONC’s Cures Act Final Rule, patients, providers, health systems,...

Cancer Registry Continuing Education (CE) Resources 2021

Michele Webb CTR Cancer Registry Leave a Comment

There are abundant cancer registry educational opportunities and resources for CTRs available today. The trick is finding the right program for your specific learning needs and budget. If you’ve not already read our recent post titled “4 Tips for Finding Great Continuing Education for Cancer Registrars” we recommend that you quickly review it before researching the list...

Spinal Fusion: Tips for Accurate Device Selection

Caitlin Wham, CCS Outpatient Coding 1 Comment

Spinal fusions can be performed using a variety of techniques, and selection of the correct sixth character is crucial in identifying the device/material used to perform the fusion. Understanding the different methods of spinal fusions and associated devices, along with Official Coding Guidelines and Coding Clinic, can help to alleviate spinal fusion confusion.   ...

Understanding Insulin to Treat Diabetes Mellitus

Becky Buegel, RHIA, CDIP, CHP Education 1 Comment

According to various sources on the Internet, the first example of recorded history began 5000 years ago – in approximately 2600 BC. An ailment thought to be diabetes mellitus (DM) was recorded by Egyptians around 1550 BC. It’s easy to see that diabetes has been around for a long, long time. Even ancient Indians were aware of the condition, as they identified diabetes...

4 Tips for Finding Great Continuing Education for Cancer Registrars

Michele Webb CTR Cancer Registry Leave a Comment

In the cancer registry profession, initial training is only meant to get you in the door. Training programs provide the best and most current knowledge they can, but a Cancer Registrar’s knowledge base is continually advancing. It does not take long for the initial training to become outdated, hence the requirement for annual training.   Continuing education, or CE, is...

Oncology Studies Corrective Action Plans for Lasting Improvement

Suzanne Neve, RHIA, CTR - Director, Cancer Registry Oncology Leave a Comment

Corrective action is an aspect of quality management that focuses on rectifying a task, process, product, service, or individual behaviors when any of these factors produce errors, deviate from the original plan or benchmarks. Corrective actions can be thought of as an improvement an organization uses to eliminate undesirable or ineffective outcomes. In this seventh, and...

Diagnostic vs. Routine Screening Colonoscopy

Erika Stevens, CPC - Senior Professional Physician Coding Specialist Inpatient Coding Leave a Comment

Read the first part of this blog, "Coverage for Medicare Colonoscopies" here.  Average Risk Colonoscopy  Average risk colonoscopy is defined as a test ordered in the absence of signs or symptoms or other evidence of illness, the physician interpreting the diagnostic test should report the reason of the test as the primary ICD-10 CM code.  The results of the test, if any,...

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