Pancreatic cancer has received greater attention in recent years, with the death of Alec Trebek and United States Supreme Court Justice Ruth Bader Ginsburg from the disease.    According to the National Cancer Institute, pancreatic cancer is "the third-leading cause of death from cancer in the United States" (behind lung and colorectal cancers). It has the highest...

A diagnosis of “Pneumonia” in the hospital inpatient setting has seen compliance reviews and Office of Inspector General (OIG) audits dating back to the early 1990s. Now hospitals (facilities) are seeing payer denials for this diagnosis, whether as a Principal diagnosis or as a Secondary (Additional) diagnosis. Keeping on top of healthcare claim denials can be daunting....

November is Gastric & Stomach Cancer Awareness month, and it is important to bring awareness to this type of cancer. My grandfather passed away in 2015 from this very type of cancer and I wish he was more informed about his symptoms. Looking back, I recalled him complaining about stomach pain and heartburn for a couple of years but never did it occur to him that it was...

Fiscal year 2023 is here with several important updates and additions to the ICD-10-CM Official Guidelines for Coding and Reporting. These guideline changes apply to discharges and patient encounters occurring October 1st of 2022 through September 30th of 2023. Although general guideline updates will be discussed in this blog, so be sure to review the new and revised...

With the increased number of Monkeypox in our communities, it’s important to understand the virus clinically and the ICD-10-CM coding of this disease. Monkeypox cases in the United States as of 9/30/2022 were 26,049 cases and two deaths according to the CDC. Over this past summer (July), the Director General of the World Health Organization, “WHO,” declared the outbreak...

In 2020 the CoC announced new operative standards and quality measures for breast, melanoma, colon, rectum, and lung primary sites. Two of the standards went into effect on January 1, 2021, including Standard 5.7 Total Mesorectal Excision (Rectum) and Standard 5.8 Pulmonary Resection (Lung). Compliance with each standard is based on documentation in the pathology reports...

Chuck B. sustained a comminuted linear skull fracture due to an auto accident. First seen in the ED he was subsequently admitted to the hospital for observation. Several days post-discharge he was back in the ED complaining of visual difficulties and a severe R-sided headache. CT scan showed an epidural hematoma. A sliver of the skull fracture had pierced the meningeal...

According to the American Cancer Society, “a risk factor is anything that increases your chances of getting a disease, such as breast cancer. But having a risk factor, or many, does not mean that you are sure to get cancer or another disease. “As with many things in life, some things we have control over, while others we don’t. Our best bet in reducing our risk for breast...

Cigarette smoking in the United States has been prevalent since the early 1900s, with approximately 3.5 billion cigarettes being sold. In 1965, congress passed legislation to place the surgeon general warning on every box of cigarettes sold in the United States. Prior to this, many Americans were not well informed or educated about the effects of cigarette smoke or even...

With the growing issues with high temperatures in many areas of the country and the world for that matter, we see related medical issues occur. Heatstroke and Dehydration are two such issues that arise when the temperatures go up. Over the past several months we have all heard about, or even experienced high temperatures where we live and work, many have been unexpected...

Technology has come a long way! With a single click, we can have items delivered to our doorstep, catch a ride to the airport, or stay connected with family or friends anywhere in the world. Many of these technological advances add convenience to our lives but let us consider how technology helps cancer registrars affect lives.   Cancer Registrars have traditionally...

Parkinson’s disease is a progressive, systemic and debilitating neurodegenerative condition of the brain with a wide range of associated manifestations. Coding and Clinical Documentation Integrity (CDI) professionals should be reading over the health record documentation carefully. Capturing the specific manifestations in the clinical documentation then in turn in the...

On January 20th, 2020, the first confirmed case of Covid-19 in the United States was reported. It was a time in history that led to fear, confusion, and many unanswered questions for millions of Americans. It presented a new fear for those who are immunocompromised or those who had family members with chronic diseases. It was a rough time around the world with millions of...

Lumbar spinal stenosis can be a pain in the – um, rump, to be polite. While causing pain in other areas of the spine, the most common area is the lower back. Lumbar spinal stenosis, or for the sake of expediency in this blog, LSS, occurs when the space inside the vertebrae is too small; the narrowed space puts pressure on the spinal cord and nerves. Though LSS often...

October is Breast Cancer Awareness Month Did you know that a “10 to 15” minute test can easily save your life? That is the amount of time an average screening mammogram takes according to the website, https://memorialhermann.org. In 1985, the “American Cancer Society and Imperial Chemical Industries” (now known as AstraZeneca) created “Breast Cancer Awareness Month” to...

Ovarian Cancer, often known as the “silent killer," or “whispering disease” among women according to Harvard.edu and NIH.gov, is considered the 5th leading cause of death in women, and the leading gynecological type of cancer death. The American Cancer Society estimates that "about 19,880 women will be diagnosed with ovarian cancer in the United States" in 2022, and close...

Have you ever wished that everything you need to get your job done, could be found in one location? A handyman or woman depends daily on their toolbox to contain most of the necessary tools needed to complete a project. Without an organized toolbox, the task of trying to complete a project could take much longer when having to search over and over for everything one needs...

Ki-67 is a tumor marker that indicates cell proliferation or how quickly a cancer cell copies its DNA and divides into two (2) cells. The more rapidly the cells divide, the faster the cancer is growing or the more aggressive it is. Ki-67 testing was added to the AJCC 8th Edition Staging Manual and may be used for treatment planning purposes or to estimate treatment...

Each year the AMA (American Medical Association) publishes new, revised, and deleted codes to the CTP code set, including logic and rationale related to the updates. In this blog, we will discuss the 2022 CPT changes regarding hypospadias repair and ultrasound-guided focal ablation of the prostate. Hypospadias Repair For FY 2022, there were several editorial revisions to...

The prevalence of pressure injury and/or pressure ulcers has continued across healthcare, with some estimates and studies saying that in the last 10 years they have increased by 63%. The proper ICD-10-CM coding of these takes clinical knowledge, comprehension and proficiency of documentation and the coding conventions and guidelines.  Deep tissue-pressure injury or DTPI,...

Effective January 1, 2022 According to STORE Manual, 2022 edition, STandards for Oncology Registry Entry (STORE v2022) (facs.org), the STORE, Standards for Oncology Registry Entry, was developed in 2014 by a group of professional Cancer Registrars, “representing CoC accredited hospitals, state registries, the SEER program of National Cancer Institute”, as well as many...

Monkeypox is a rare virus that has been increasing in frequency over the past 3-4 months here in the United States. Vaccinating against Monkeypox is a recommended medical practice. Having the associated laboratory test code and vaccine product code(s) to capture this service and data is important to have in place for use across healthcare settings. Monkeypox is a rare...

The National Cancer Institute defines cancer prevention as “action taken to decrease the chance of getting a disease or condition.” They further define decreasing risk factors, such as smoking, obesity, and lack of exercise. They also define increasing protective factors, such as regular physical activity, vaccination, staying at a healthy weight, and having a healthy...

Effective September 1, 2021, for all cases diagnosed January 1, 2022, and forward. This week we wrap up the remaining changes made to the Solid Tumor Rules. As with the previous sites, changes have been made to both the multiple primary and histology sections, as well as different tables within each section. Several of these changes also reflect several changes made to...

Leaders at Carolina Community Health share their experiences on outsourcing revenue cycle management processes to ensure the success of the organization.   Among the top concerns for chief financial officers (CFOs) and vice presidents (VPs) of revenue cycle these days are labor shortages, increasing costs, insufficient capacity causing care delays, and recession....

Effective September 1, 2021, for all cases diagnosed January 1, 2022 and forward.  As stated in the SEER online article, What is a Cancer Registry?, “cancer registries receive and collect data about cancer patients,” that is securely stored and submitted to other organizations, such as state Central Registries, SEER (Surveillance, Epidemiology, and End Results Program),...

What do hypertropia, crossed eyes, and strabismus have in common? They’re different names for the same condition – misalignment of the eyes. Using the nose as the “common landmark” as it were, the condition that causes an eye to deviate away from the nose, while the other remains focused is a form of strabismus diagnosed as exotropia. The condition that causes an eye to...

Effective September 1, 2021, for all cases diagnosed January 1, 2022 and forward.  One of the most popular manuals used daily by cancer registrars is the Solid Tumor Rules. This manual helps determine which histology to use and the number of primaries to abstract when a patient has multiple biopsies and diagnoses. The Solid Tumor Rules manual, previously known as “The...

The Inpatient Prospective Payment System (IPPS) methodology utilizes the major complication or comorbidity (MCC) and complication or comorbidities (CC) designation for specific ICD-10-CM codes to impact the relative weight (RW) of certain Medicare-Severity Diagnostic Related Groups (MS-DRGs). Identifying the MCC/CCs in the clinical documentation is a vital component to...

Effective September 1, 2021, for all cases diagnosed January 1, 2022 and forward. Daily cancer abstracting requires the use of many manuals to abstract a patient’s case daily. One such manual is the Solid Tumor Rules manual by the Surveillance, Epidemiology, and End Results Program (SEER). The use of this manual, which according to the CancerRegistryeducation.org...

Each year the AMA (American Medical Association) publishes new, revised, and deleted codes to the CTP code set, including logic and rationale related to the updates. The CPT code set for 2022 includes several changes to the urinary system as well as a new Category III code. In this blog, we will discuss the changes regarding periurethral balloon continence device...

The annual ICD-10-CM classification system update for FY2023 brings many new codes and included in this we find three new codes for the Social Determinants of Health or SDOH category. Attention for capturing SDOH continues across all healthcare settings. Ensuring that clinical documentation and coding are in sync is a priority.  It is well known that socioeconomic...

The daily struggle is real for cancer registrars with each abstract on how to stretch 1000 characters per text box while reporting a patient’s cancer story.  Eight thousand characters may sound like a lot until you start typing away. How many times did you focus on typing the patient’s information into a text box just to find out you already reached your 1000-character...

As every coder knows, the hip, one of the largest joints in the body, is a ball and socket joint. Looking at the hip’s anatomy, the “socket” portion is formed by the acetabulum, and the “ball” is the upper end of the femur. The bony surfaces of the hip are covered by articular cartilage that cushions the bones, permitting easy movement. The synovial membrane surrounding...

Each year the AMA (American Medical Association) publishes new, revised, and deleted codes to the CPT code set, including logic and rationale related to the updates. The CPT code set for 2022 includes several changes regarding osseointegrated auditory implants. These changes include revisions of guidelines and parenthetical notes, as well as new, revised and deleted...

In September 2020, the well-known RQRS and NCDB Call for Data submissions programs were phased out with the release of the Commission on Cancer’s (COC) National Cancer Database (NCDB) new Rapid Cancer Reporting System (RCRS). The RQRS along with NCDB’s Call for Data, were both important tools used for quality improvement and real time reporting in accredited CoC...

Digital technologies play an important role in meeting the challenges of the post-pandemic world. Top agenda items for health systems moving out of the pandemic involve developing virtual care models, methods for coping with the financial aftermath, and crisis management lessons learned. Developing Virtual Care Covid-19 caused businesses and health systems to pivot...

In 2020, Congress designated the new 988 dialing code to be operated through the existing National Suicide Prevention Lifeline. Beginning July 16, 2022, 988 will be the new three-digit dialing code connecting people to the existing National Suicide Prevention Lifeline, where compassionate, accessible care and support is available for anyone experiencing mental...

While writing policies and procedures often seem to be time-consuming and a challenge, they have many positive benefits that cannot be overlooked. For Clinical Documentation Integrity (CDI) program having written policies and procedure is part of compliance and the day-to-day operations of the CDI staff. When we think about written policies and procedures (P&Ps) we often...

The Centers for Medicare and Medicaid Services (CMS) released their proposed Fiscal Year 2023 ICD-10-CM coding update and the final ICD-10-PCS codes changes. The ICD-10-CM proposal has some significant changes and new codes. The ICD-10-CM does have a high volume of new code to absorb and learn about. The ICD-10-PCS is always of interest with new procedure and devices...

Recent media reports document an increase in suspected and confirmed cases of the monkeypox virus. Monkeypox, first detected in lab monkeys in 1958, may have earned its moniker from the lab monkeys, but it’s actually thought it originally spread to humans from wild animals like rodents; today’s thinking is that it’s either spread by wild animals or from contact with other...

Each year the AMA (American Medical Association) publishes new, revised, and deleted codes to the CTP code set, including logic and rationale related to the updates. The CPT code set for 2022 includes several changes regarding spinal fusions- including revisions of guidelines, parenthetical notes, definitions and coding instructions. The key changes regarding spinal...

The 2021 Comprehensive Error Rate Testing (CERT) report contains statistics on improper payment made by the Medicare program to providers and is published annually. The CERT data is supported by a sample of Medicare Fee-For-Service (FFS) claims that were reviewed by an independent medical review contractor to determine if they were paid properly under Medicare coverage,...

The clinical coding of “Underdosing” has some very specific guidelines which must be understood and followed. We see “underdosing” scenario’s occur in both outpatient and inpatient encounters. Several ICD-10-CM codes will need to be assigned in order to capture the underdosing patient encounter accurately.  The clinical coding of a condition or diagnosis of “Underdosing”...

The question is simple – What is anemia? However, the answer is not necessarily so simple. Anemia is a condition that is marked by a deficiency of red blood cells, or hemoglobin. Anemia can be linked to a variety of conditions and diseases, and can affect people of all ages, races, and ethnicities. The more common forms of anemia are noted below.  NUTRITIONAL-DEFICIENCY...

Within Clinical Documentation Integrity (CDI) and clinical Coding we have verbal, written and electronic documentation clarifications or querying. A key component of the clinical documentation query is achieving and maintaining compliance. Having a written policy and procedure in place along with a formal quality review process for querying is thus essential and a must. ...

In March 2022, the U.S. Department of Health and Human Services released the updates for its Strategic Plan. All operating and staff divisions within the HHS and input from Congress, Tribes, Tribal, and Urban Indian Organizations, the Office of Management and Budget, and the public sector contributed to its development. For FY 2022 – 2026, HHS addresses and tracks five...

Each year the AMA (American Medical Association) publishes new, revised, and deleted codes to the CPT code set, including logic and rationale related to the updates. The CPT code set for 2022 includes extensive changes to the Musculoskeletal System section, which had a large number of updates in both guidelines and definitions. The key changes to the Musculoskeletal...

The Office of Inspector General (OIG) released in mid-March 2022 their annual report and statistics for 53 Medicare Fraud Control Units across the country. Significant investigative work and recoveries were obtained in 2021 totaling $1.7 billion recovered and 1,105 convictions. The 2021 annual Office of Inspector General (OIG) Medicaid Fraud Control Units (MFCUs) report...

Your next chart has the diagnosis “scleroderma.” Being familiar with medical terminology, you know “sclero” means “hard”. Derma, of course, means skin, so the diagnosis means hard/hardened skin. If you’re using coding books instead of an encoder, you’re probably thinking skin codes fall under Chapter 12 – Diseases of the Skin and Subcutaneous Tissue as you flip through...

The CPT code set for 2022 includes 249 new codes, 93 revisions, and 63 deleted codes that went into effect January 1st, 2022. Changes in codes and guidelines were made in all sections of CPT- so be sure to review the 2022 CPT code set in its entirety to ensure proper coding and reporting. Key changes in the Surgery section will be highlighted in this blog. Integumentary...

Pituitary adenomas are tumors of the anterior pituitary gland. Most are slow-growing and benign. They are classified based on size or cell of origin and described as microadenoma, macroadenoma, or giant tumors. Microadenomas are usually less than 10 mm in size, while macroadenomas are larger than 10 mm. Giant pituitary tumors are bigger than 40 mm. Adenomas are further...

Proper charge capture processes are essential to compliance regulations. An outdated, non-existent, or poorly thought-out charge capture workflow can be devastating to a hospital and healthcare system’s bottom line. Overcharging can be just as harmful as undercharging for medical services. The key to appropriate charge capture processes has shifted from a solely...

In 2021, CMS released the Official ICD-10-PCS Coding Guidelines for fiscal year 2022, which went into effect October 1st. The FY 2022 PCS guidelines include three guideline revisions in the Medical and Surgical section (B3.7, B4.1c, B4.8) and two guideline revisions from the New Technology section (E1.a, E1.b). Although key changes will be highlighted in this blog, be...

The Commission on Cancer (CoC) requires accredited programs to treat cancer patients according to nationally accepted measures endorsed by the CoC. The measures are included in the Rapid Cancer Reporting System (RCRS) tool for monitoring and reporting purposes. Standard 7.1 states that each calendar year the expected performance rate should be met for each of the quality...

Over the past 20 years, Healthcare has seen an increased interest in the impact and influence of “Social Determinants of Health” or SDOH. Recent the Centers for Medicare and Medicaid Services (CMS). Health plans themselves have become more interested in SDOH and the associated cost of care present and future. Now we have CMS Medicare Part C raised attention to SDOH also. 

The CPT coding system was introduced in 1966, and was originally intended to simplify documenting procedures that physicians performed. By 1970, the system had changed to include lab procedures, and the codes had expanded to five digits. The concept of modifiers was introduced in the third edition of CPT in 1973. Modifiers provide additional information about a procedure...

We don’t live in a bubble. We are a globalized economy. Until artificial intelligence has total capability in healthcare, the human touch is what sets us apart from just carrying out a set of functions efficiently. Since the COVID-19 pandemic landed, it has had an unprecedented impact on most countries, and an already taxed U.S. health system regarding mental health and...

The Office of Inspector General released in January 2022 an audit report on Medical Advantage for Healthfirst Health Plan, Inc. The identified errors were related to some specific diagnosis codes and Hierarchical Condition Categories (HCCs). Another Medicare Advantage Audit Report from the OIG! This particular audit report by the Health and Human Services (HHS) Office of...

Cancer screening saves lives and reduces the burden of cancer in the United States. However, gaps in screening programs mean far too many in the US are presenting with late-stage disease or dying from cancers that were preventable or could have been detected at an earlier stage. The socially and economically disadvantaged populations are often at higher risk for cancer...

Just about anyone who’s taken medical terminology recognizes the term “eponym”. The Merriam Webster dictionary, along with the Wikipedia website have the same definition for the word “eponym”. Roughly paraphrased, an eponym puts the name on a place, thing, discovery, or invention of the person who is believed/thought to have “discovered” it. Being awarded an eponym in...

Finding purpose through meaningful work has been on the minds of many lately. Purpose, essential to organizational development and the lifeblood of the human heart as it relates to the whole organizational body system, is what makes life meaningful. Often, health care workers enter the health care field because they love to help people and contribute to enhancing a...

Melanoma is a type of skin cancer that arises in the melanocytes or cells that produce melanin and determines the color of your skin, or pigment. Melanoma can form in the eyes, and on rare occasions inside the body such as the nose or throat. Its exact causes are not always clear, but evidence does support exposure to ultraviolet (UV) radiation from sunlight or tanning...

The Office of Inspector General (OIG) “Work Plan” is a roadmap to many compliance focused areas across healthcare. In addition, the Work Plan can serve as an audit plan for many healthcare settings identifying where compliance risks of overpayments are from federally funded programs. With the focus on specific Health and Human Services (HHS) programs, the OIG Work Plan is...

In 2021, CMS released the fiscal year 2022 code descriptions, tables, index and addendum which went into effect October 1st. The updates included 32 deleted codes, 20 revised codes, and 159 new codes. Although key changes will be highlighted in this article, be sure to review both the guidelines and code updates in their entirety to ensure proper coding and reporting. ...

On April 6, 2022, the National Cancer Registrar’s Association (NCRA) will kick off its annual educational conference at the Gaylord National Resort and Convention Center in Washington, DC. This year’s conference will offer a first-time ever hybrid experience where virtual attendees can watch the live streaming of the in-person sessions and take part in the live Q&A. Early...

When I first heard about concurrent abstracting years ago, I thought “they have got to be kidding”. Now, many years later, it is my reality. I have been doing concurrent abstracting since December of 2016. Although concurrent abstracting has many advantages, there are also disadvantages.  What is Concurrent Abstracting? Concurrent abstracting is when you complete the...

The Fall 2021 Office of Inspector General (OIG) Health and Human Services Semiannual Report to Congress describes work identifying significant risks, problems, abuses, deficiencies, remedies, and investigative outcomes relating to the administration of HHS programs and operations that were from the reporting period of April 1, 2021, through September 30, 2021. The HHS...

Joining the ranks of physician and nursing shortages is a medical coder shortage of unprecedented heights. Hospitals need to quickly alleviate this problem or risk losing thousands of dollars in unbilled charges. Here’s a look at four actionable solutions to the coder shortage gap in hospitals. First, why is there a coder shortage? Sickness running rampant throughout an...

According to the American Cancer Society (ACS) estimates, 608,570 deaths will occur from cancer in the United States in 2021. About 45% are attributed to potentially preventable, pre-pandemic causes such as tobacco smoking, obesity, alcohol intake, physical inactivity, and an unhealthy diet. In the ACS report Cancer Prevention and Early Detection Facts & Figures,...

On December 8, 1941, President Franklin D. Roosevelt declared, “… December 7, 1941 – a day that will live in infamy….” when the USA was suddenly attacked by Japan. Many died from the attack itself and the ensuing world war into which America was thrust. On March 11, 2020, WHO declared COVID-19 a global pandemic (an infectious disease that has spread, in this case,...

Introduction Heart disease, which includes coronary artery disease (CAD), is the leading cause of mortality in the U.S. To reduce the incidence of mortality, approximately 1.2 – 2 million cardiac stents are implanted each year worldwide. A cardiac stent or stents are deployed (inserted) into one or more affected cardiac arteries most commonly via a minimally invasive...

I am the sole tumor registrar at a small Commission on Cancer (CoC) accredited facility in the state of Vermont. I have been employed there for over five years. Because I am the only registrar, I am responsible for all the tasks that are involved in maintaining the tumor registry.  When I first started here, I worked 2.5 days at a hospital location and 2 days remotely...

In June 2020, the American College of Surgeons (ACoS) launched the Cancer Surgery Standards Program (CSSP) quality program to shift from standards based in facilities / equipment to outcomes-based standards. There is growing evidence-based research suggesting that adherence to specific operative reporting techniques leads to longer survival, better surgical outcomes and...

When the final rule for the FY2022 Inpatient Prospective Payment System (IPPS) came out, it included the statement that we will now have clinical coding updates twice a year for ICD-10-CM and ICD-10-PCS, once in April and the usual large update in October. Keeping with their statement, the Centers for Medicare and Medicaid Services (CMS) announced that three (3) new...

The Improper Payment Measurement or IPM provides statistical data on parts of the Medicare programs and reports overpayments and underpayments. The Medicare Part C beneficiary-level of payment errors from a given year is included and certainly is something to keep an eye on. The CMS IPM sample taken is extrapolated to determine the payment error to the risk adjustment...

The “coding” for HCCs (Hierarchical Condition Categories) is not for the faint of heart. As an outsider or non-coder, looking in, it would appear to be so simple, BUT, It is not simple or easy. No one should do HCC coding without extensive documentation and coding training as well as HCC code capture training – and preferably this person should be a certified coding...

Another Office of Inspector General (OIG) audit report which targets Medicare Advantage (MA) risk adjustment (RA) diagnoses has been released. This November audit report was focused on University of Pittsburg Medical Center (UPMC) Health Plan, Inc, and “high-risk” diagnosis from 2015-2016. This focused audit may sound familiar as we have seen several audit reports from...

CAM? Isn’t she some female American country music singer/songwriter? No – a CAM is a rotating or sliding piece in a mechanical linkage that has something to do with turning rotary motion into linear motion – at least that’s what the dictionary said. Besides, what would have female country music singer or a car engine part have to do with acupuncture? Well, they have...

According to a Pew Research Center analysis, retirement looms for 3.5 million retirees over the next year, including the most recent labor force data.1 Many organizations face this worrisome predicament, yet many health information management departments struggle with being proactive in their planning efforts. This week's blog post asked three healthcare industry leaders...

On November 2nd, 2021, the Centers for Medicare, and Medicaid Services (CMS) released their 2022 Physician Fee Schedule (PFS) final rule, which is 2,414 pages in length. Included in this policy ruling was also some other Medicare Part B issues. The PFS rule making is part of the Biden Administration strategy of better accessibility, quality, affordability, empowerment,...

Several important updates and additions were made to the ICD-10-CM Official Guidelines for Coding and Reporting for fiscal year 2022. Although key changes will be highlighted in this article, be sure to review the new and revised guidance in its entirety to ensure proper diagnosis coding and reporting. Additionally, visit our blogs about 9 Tips to Calm Coder Anxiety, ...

The purpose and intent of palliative care is often misunderstood. In 1990 the World Health Organization (WHO) recognized palliative care as a distinct medical specialty dedicated to relieving the suffering and improving the quality of life for patients with life-limiting illnesses, chronic disease, or serious injury. Despite its twenty-plus year history, many healthcare...

The Hospital Outpatient Prospective Payment System (OPPS) Final Rule for Fiscal Year 2022 has been released by the Centers for Medicare and Medicaid Services (CMS). Included in the 1394 page OPPS final rule announcement that came on 11/2/2021 was the 2022 payment policy for Ambulatory Surgery Centers (ASCs) which is available at: ...

Metrics represent values to measure an organization’s strategy. Leaders should understand that metrics cannot replace strategy. It can lead to behaviors that undermine the very strategy the metrics expect to measure, resulting in negative consequences for all. Remember the severe negative repercussions the banking giant, Wells Fargo experienced when it aggressively pushed...

The American Medical Association (AMA) announced the addition to the Current Procedural terminology (CPT® ) code set of a new COVID-19 booster for the Janssen Pharmaceutical Companies of Johnson & Johnson vaccine. The October 27, 2021, AMA press release explains that this vaccine is added to the other booster vaccine doses from both Pfizer and Moderna. The new CPT code...

Deciding whether a spinal cord tumor is reportable or not can be a daunting task for even experienced cancer registrars. The decision-making process used for correct case-finding must begin with an understanding of the anatomy, terms and definitions used, and how benign and malignant spinal cord tumors are classified.     Spinal cord tumors are defined by their position...

Diabetes mellitus (DM) Types 1 and 2 are both known to be associated with a variety of complications. Some complications, like kidney disease or ophthalmic problems are, more often than not, related to poorly controlled diabetes. Acute metabolic complications are one of the many different types of complications that can develop in patients with diabetes. These...

The last 12-18 months has brought the healthcare industry many audit reports from the Office of Inspective General (OIG). These reports are always an important part of every Compliance Program and the related audit and educational activities. Certainly, for Health Information Management (HIM), the OIG audit reports can provide a lens into issues, vulnerabilities, and...

Across the Medicare Advantage (MA) Risk Adjustment (RA) healthcare world, we often hear about “Star Ratings.” With the October MA Star Ratings being released by the Centers for Medicare and Medicaid Services (CMS) a common question is: What are the CMS Star Ratings? CMS publishes the Medicare Part C and Part D Star Ratings each year to measure the quality of health and...

Back in October 2012 (which is fiscal year 2013) the Hospital Readmission Reduction Program or HRRP was started in accordance with Section 1886(q) of the Social Security Act. This regulation set forth the statutory requirements for HRRP, which required the U.S. Department of Health and Human Services (HHS) via the Centers for Medicare and Medicaid Services (CMS) to reduce...

Lung Cancer Awareness is observed in November of each year and reminds us of some important facts.    Lung cancer is the number one cause of death in the United States for men and women. According to the American Cancer Society (ACS) Cancer Facts and Figures 2021, an estimated 235,760 new lung cancer cases will be diagnosed in the United States in 2021 and 131,880...

There are many hints within the tabular index of the new ICD-10-CM codes for FY2022 that may help identify documentation query opportunities. Take a close look at these new codes, see those instructional notes; “Code first,” “Use additional code”, “Code also”, these are some the documentation hints. In addition, some of the new codes have a description or title that...

Summary   As the world of healthcare becomes more complex, healthcare executives are searching for ways to curb costs quickly and substantially while remaining competitive and profitable. Outsourcing is one way to reduce inefficiencies and eliminate redundancy. Let's explore some of the pain points health systems and hospitals face along with the pros and cons of using...

The Centers for Medicare and Medicaid Services (CMS) released a compliance reminder regarding, “Non-Physician Outpatient Services Provided Before or During Inpatient Stays: Bill Correctly” in their October 14th, 2021, Medicare Learning Network (MLN) news. Understanding this particular CMS policy, one needs to review the language: Medicare’s 3-day (or 1-day) payment window...

Dermatology is one of the more complex specialties in medical billing and coding, with a wide range of procedures that can be performed either in the office or in the same day surgery setting. An in-depth understanding of dermatology CPT codes and the appropriate use of modifiers is crucial to ensure accurate coding and reimbursement. Modifier 59 Modifier 59, Distinct...

More changes are coming to the Commission on Cancer (CoC) online portals and how cancer programs access information and resources for accreditation. In a recent news brief the CoC announced that Datalinks, the current online portal, will be replaced by the new ACS Quality Portal, or QPort, as early as late October 2021. Programs in process of resolving a deficiency from a...

On October 1st, 2021, a report from the Office of Inspector General (OIG) was released regarding the Centers for Medicare and Medicaid Services (CMS) coverage violation of insertion or replacement of Neurostimulator Implantation surgeries. CMS had performed an analysis of prior Part B claims data and identified concerns and thus directed a supplemental post-payment...

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...

Chapter 21 in ICD-10-CM contains our “Z” codes. Z codes (other reasons for healthcare encounters) may be assigned as appropriate to further explain the reasons for presenting for healthcare services, including transfers between healthcare facilities, or provide additional information relevant to a patient encounter. The ICD-10-CM Official Guidelines for Coding and...

The American Medical Association (AMA) has announced their 2022 Current Procedure Terminology (CPT ®) new codes and changes. For 2022, there are 405 editorial changes in the 2022 CPT code set, including 249 new codes, 63 deletions and 93 revisions. So, for the coding professional, there is a lot to understand and learn about these new codes and changes. According to the...

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. 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...

What another crazy year, huh?! In 2021, the OIG continued to publish its work plan with monthly updates including OIG audits and evaluations for the fiscal year and beyond. Although the COVID-19 pandemic continues on, healthcare operations and government oversight entities such as the OIG continue their work. As of the end of November 2021, the OIG had published 12 new...

We’ve heard about government investigations into unnecessary cardiac stent placement and cardiac ablation procedures in the past. On September 15th, 2021, the Department of Justice (DOJ) announced a settlement was reached in a case involving unnecessary cardiac procedures once again. This case is titled, “Orlando Cardiologist Pays $6.75 Million to Resolve Allegations of...

As coders we are often torn when it comes to coding a diagnosis when the provider’s documentation isn’t perfectly clear. It may sound elementary, but we must go back to the Official Coding Guidelines and stick to those to ensure we are reporting the correct diagnosis based on the documentation. Per the Official Coding Guidelines, Section IV.H, “Do not code diagnoses...

The Office of Inspector General (OIG) released another Medicare Advantage (MA) report, this time indicating the several Medicare Advantage companies were/are leveraging chart reviews and health risk assessments (HRAs) to drive up MA hierarchical condition category (HCC) diagnosis payments. One certainly can notice that the OIG has been publishing reports on a variety of...

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,...

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...

It’s September so that means it’s the beginning of Fall AND it’s Sepsis Awareness Month. Who would have thought we needed a month dedicated to this topic? But we do! Over the past 20 or so years the topic of Sepsis, Septicemia, Septic Shock and alike has flooded healthcare research, conferences, and medical literature. Certainly, for HIM Coding and Clinical Documentation...

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.   ...

We continue with our discussion of “Respiratory Failure, please refer to Part I for information on the clinical aspects and on the ICD-10-CM coding classification of this diagnosis. Often we think of “respiratory failure” as a condition occurring in the inpatient setting, but it can also occur in the Emergency Room, but usually results in an admission. Medicare-Severity...

You’ve heard of them . . . NCDs or National Coverage Determinations. What are they really? Who do they apply to? And how can I learn more? National Coverage Determinations are specific to the United States healthcare system, and they fall under the Health and Human Services Department (HHS). They are specific coverage determinations which apply to Medicare for items,...

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...

The Food and Drug Administration’s (FDA) took action in the month of August 2021 to authorize an additional dose of COVID-19 vaccine for immunocompromised individuals, referred to as a “COVID Booster”. Both Pfizer and Moderna have been approved for this the third COVID-19 vaccine. Administration of the COVID-19 booster will first be provided to those with...

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...

The Medicare-Severity Diagnostic Related Groups (MS-DRGs) with ICD-10-PCS mechanical ventilation code(s) have been cited by the Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector (OIG) as problematic and a compliance risk. In a June 2021 CMS Medicare Learning Network (MLN) publication #17107 ”revised”, this included mechanical ventilation...

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...

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) in early August 2021 published a report titled, ”Medicare Continues to Make Overpayments for Chronic Care Management Services, Costing the Program and Its Beneficiaries Millions of Dollars”. The OIG conducted this audit with the objective to determine whether payments made by the Centers...

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,...

Do you have trouble with IR coding? It can be difficult to determine code selection but understanding the rules can go a long way to understanding how CPT code assignment works. It’s all about the position of the catheter and the hierarchy of the codes. In a non-selective catheter placement, the catheter stays in the original vessel that was punctured or advances only to...

The Centers for Medicare and Medicaid Services (CMS) released on August 2nd, the Fiscal Year 2022 final rule for both Inpatient Prospective Payment System (IPPS) and the Long Term Care Hospital (LTCH) Prospective Payment System. After receiving more than 6500 comments to the proposed rule for IPPS and LTCH PPS, the results include a policy regarding healthcare equality...

In our sixth installment in this series on oncology quality studies we will look at the value, challenges, and recommendations for benchmarking oncology data.   Benchmarking is an excellent way to identify opportunities to enhance clinical practices, workflows, procedural efficiency, cost-effectiveness, utilization, and financial outcomes. There are many sources for...

Throughout the years when working with and on hospital coding of inpatient encounters, I have found that the principal diagnosis was always a topic of discussion when it comes to coding accuracy determination. It certainly is important to understand the guidelines for the selection of the principal diagnosis for the Health Information Management (HIM) coding professional...

With several major events including the pandemic and its domino effects (e.g., social isolation, job loss), racial strife, natural disasters, and senseless shootings the past eighteen months or so has taken its toll on humankind in the form of increased mental health distress and drug abuse. The increase in mental health challenges patients are facing provides a good...

Hip and knee replacements have been around for several decades, in fact, the first recorded attempt for a total hip replacement dates all the way back to 1891 when they created a femoral head replacement out of ivory. Hip and knee replacement procedures and implants have evolved since then of course, and today the implants are made of metal, plastic, or ceramic material. ...

For twenty-four (24) years now the Department of Justice (DOJ) has been in combat against healthcare fraud and abuse through the “Healthcare Fraud and Abuse Control Program” or HCFAC. We can be thankful for HIPAA (Health Insurance Portability Accountable Act) which put in place the national program. The HCFAC program is under the joint direction of the United States...

Megaloblastic anemia is a form of anemia that occurs when the body’s bone marrow produces structurally abnormal and unusually large, immature red blood cells known as megaloblasts. A deficiency in healthy, mature red blood cells can result in fatigue, pallor, lightheadedness, aches and pains, muscle weakness, and dyspnea. Other symptoms can include gastrointestinal...

WOW! The FY2022 Official Guidelines for Coding and Reporting were released on July 12th, 2021, which was earlier than expected. The big topic within the guidelines is the Post COVID-19 guidance. Plus, there are several other additions/changes in the General Coding Guidelines which should be reviewed carefully. This blog will cover “some” of the changes, additions,...

About 10% of neonates require some form of respiratory assistance at birth. To assign ICD-10-PCS ventilation codes correctly, it is important for Coding Professionals to understand the difference between invasive and noninvasive ventilation. An understanding of respiratory assistance given solely for the purposes of newborn resuscitation vs ongoing respiratory assistance...

For those of us within the Health Information Management (HIM) profession and even Clinical Documentation Integrity (CDI) profession one of the main aspects to our jobs, our careers, is in fact obtaining “Education and Training”. Although related to each other, education and training are not exactly the same. First let’s discuss “education” and its’ meaning in the context...

In this fifth installment of our series on oncology quality studies we will discuss the preparation and writing of the summary analysis and study results. See links for parts 1-4 below.  Although there are no official content outlines for writing the final report, it is important to have a written document that states the project’s goals, lists the strategies used to...

Don’t you love summertime? School is out, we are taking vacations and trips, barbeques, sunny days, AND the new ICD-10-CM codes get released! Yes, it has occurred already (earlier than expected), the FY2022 ICD-10-CM codes have been released by the Centers for Medicare and Medicaid Services (CMS). For those of you keeping track of the dates of these releases, this FY2022...

My first blog on Diabetes Mellitus (DM) covered the pathophysiology of DM Types 1, 1.5, and 2. Read Part 1 Here. Types 1 and 2 (and even 1.5, though not “officially” recognized) are considered primary types of DM. There are other forms of DM that are due to underlying conditions or are “induced” by drugs or chemicals. Complications of primary DM include: hyperglycemia,...

The cancer registry network is a powerful resource in oncology healthcare. The connections and relationships with members of the cancer care team are a valuable source of knowledge and provide many opportunities for resource-sharing and growth. The cancer registry should never be maintained solely for the purpose of meeting minimum reporting requirements. Instead, it...

In this article we will highlight some key elements for Critical Care coding since these codes are watched closely by insurance payors. What is the definition of Critical Care? Per American Medical Association (AMA) CPT Professional 2021 codebook, critical care is defined as “…the direct delivery by a physician(s) or other qualified healthcare professional of medical care...

According to a recent Centers for Medicare and Medicaid Services (CMS) MLN Connections, Medicare Administrative Contractors (MAC) are beginning to conduct post-payment medical reviews for dates of services (DOS) after March 2020. After a pause in audits due to the COVID-19 pandemic, the MACs already did resume audits on post-Payment items or services before March 2020....

Colonoscopies are critical to our well being. How these important services are documented and coded is equally as important. Medicare covers screening colonoscopies every 24 months if the patient is at high risk for colon cancer or once every 120 months, or 48 months after a previous flexible sigmoidoscopy. No cost to the beneficiary for screening colonoscopies and the...

Recently I was talking with a colleague about the most common coding errors or variances we’ve been seeing lately when conducting inpatient coding audits. The selection of the “Principal Diagnosis” and a “Missed or Unsupported Secondary Diagnosis” certainly were at the top of the list. But there are some other areas that we as HIM Coding professionals should also be aware...

Lots of excitement over the release of the FY2022 ICD-10-PCS (Procedure Coding System) changes which came out on June 4th, 2021. In addition, there are a few changes to the PCS “Official Guidelines” (i.e., 3.7B Control), that every inpatient coding professional needs to be aware of and understand. For FY2022 there are 191 new codes, 62 revised titles, and 107 deleted...

In my estimation, we in healthcare, love initials after our last names. While I have no actual data to support my “theory”, I’d say that most of us involved in healthcare (whether practitioners or allied health professionals) have more than one credential. Professional credentials are our way of proving our expertise in a given subject such as HIM, coding, compliance, CDI...

One of the more challenging areas of medical coding, is the diagnosis of “Respiratory Failure”. Not only does it take having a solid clinical understanding but also a succinct knowledge of the Official Guidelines for Coding and Reporting as well as knowing when to query for documentation specificity. Obtaining coding compliance does center around continually learning and...

Throughout my career in Health Information Management, one of the particular areas of focus for both auditing and education has been the coding of an additional or secondary diagnosis. Whether inpatient (acute care) or outpatient coding, confusion and even errors occur in this area. The Official Guidelines for Coding and Reporting are at the center of understanding when,...

In this fourth installment of our series on oncology quality studies we will talk about conducting the study according to the planned methodology or quality measures and how to organize the data collection process. The methodology is the roadmap, or strategy, that describes the way the study is to be conducted and identifies the methods to be used during the process. The...

Medicaid provides coverage and healthcare services with federal and state funding to 72.2 million people in the Unites States. This coverage is for those with limited income and resources i.e., low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid is administered by the “States” under federal requirements and guidelines. Like...

On June 3 – 5, 2021 cancer registrars across the country came together for the National Cancer Registrar’s Association (NCRA) 47th Annual Educational Conference. This year’s event was held virtually and offered up to 29.25 continuing education (CE) hours featuring workshops and presentations from the standard-setting agencies and cancer registry community. Conference...

Protecting the Medicare Trust Fund is an important priority for the Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS), the Office of Inspector General and thus we have Recovery Audit Contractors or “RACs”. Through the Medicare Modernization Act of 2003, CMS established the Recovery Audit Contractor program with a focus on...

As value-based healthcare models continue to grow, the collection and documentation of social determinants of health data has become a key factor in improving patient care and outcomes. As HIM and Coding Professionals, our role in understanding, collecting and appropriately reporting social determinants of health is more important than ever. What are social determinants...

We all are aware of the currently available COVID-19 vaccines from AstraZeneca, Janssen (Johnson & Johnson), Moderna and Pfizer and their unique CPT® codes. These medical codes allow for each vaccine and immunization administration to be clinically distinct, allows for better tracking, reporting and analysis (i.e., utilization data). The American Medical Association has...

As coders, we often encounter common coding scenarios that seem straightforward, but we may need to be reminded of applicable guidelines and coding advice. Sometimes this requires us to seek further clarification if the documentation is not clear. With awareness of the documented circumstances and pertinent guidance, the potential implications for inaccurate coding can be...

Another Office of Inspector General (OIG) Medicare audit report was released in early May 2021 titled, “Medicare Hospital Provider Compliance Audit: Virtua Our Lady of Lourdes Hospital”, this hospital is located in New Jersey. These ongoing OIG Medicare audit reports are important to review, internally discuss and determine if any additional or specific steps should be...

We have covered the first two steps in this multi-part series. In Step 1 we talked about assembling a team of experts to participate in the study project. In step 2 we identified the problem statement. Now, in Step 3 we will look how the study is conducted and the methodology used to structure the analysis.   Quality studies are, by intent, a process that is used to help...

Certain elements of documentation must be present to code infusions, injections, and hydrations properly. An order by the physician, which must be dated, timed, and signed with the name of the drug, the dose and the route of administration should be on file for services performed. Infusion services require direct supervision by medical staff. The coder should next ask a...

With the last 14 months being impacted by the COVID-19 public health emergency (PHE), we experienced significant changes and revisions to policies across the continuum of healthcare. It’s time once again for the Inpatient Prospective Payment System (IPPS) proposed rule for the coming fiscal year 2022 (FY2022). Here are “some” highlights from the CMS proposed IPPS rule: ...

Active wound care procedures are performed to remove devitalized and/or necrotic tissue to promote healing. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. These services are billed when an extensive cleaning of a wound is needed prior to...

Over the past year I like you have seen and read more and more about the reporting of Social Determinants of Health or “SDOH". Clearly there has been a COVID-19 impact to the overall interest in these social economic and psychosocial aspects of an individual. More research and studying of our healthcare social equity and inequality is on the top of all healthcare...

There’s an old saying about “writing what you know.” Keeping that in mind, I’ve decided to write a series of blogs about diabetes mellitus (DM) since I have Type 2 DM. Actually, I suspect I really have Type 1.5, AKA LADA. You may not even know the terms Type 1.5 or LADA, as presently, there is no official recognition or code number for Type 1.5. However, before we can...

The Office of Inspector General (OIG) released a recent report (4/2021) titled “Medicare Advantage Compliance Audit of Diagnosis Codes that Humana, Inc., (Contract H1036) Submitted to CMS”, which should wave a flag for compliance and Health Information Management coding professionals. Under Medicare Advantage (MA), the risk adjustment (RA) determination is made using...

Quality studies and improvements have much more value than merely meeting a cancer program standards requirement. If planned well and properly conducted, quality studies can energize the members of the team, reduce inefficiencies, increase cost effectiveness, and deliver value to the organization and patients it serves.   Read Part 1 of this article series HERE.  The...

Have you noticed that we are reading and hearing more and more about ICD-11? Looking back over the past few years we see that in June 2018 the World Health Organization (WHO) published (released) ICD-11 for review and the World Health Assembly formally adopted this version on May 25, 2019 to be effective beginning January 1, 2022. In fact, WHO has a home page dedicated to...

And What the Future Might Hold By Stephanie Kovalick  For years, healthcare industry pundits have been predicting that we’re on the verge of a tipping point in value-based payment (VBP) and/or care. In a 2016 survey of 115 payers by ORC International and commissioned by McKesson, respondents predicted that VBP—such as pay-for-performance, global payment or capitation,...

Current Procedure Terminology or CPT® is the registered trademark of the American Medical Association (AMA). The codes in CPT are 5-characters in length, with over 10,300 Category I, II and III codes, Category I covers the Evaluation and Management visits, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and the Medicine Section codes. It is within the Medicine...

When working from home it is important to keep the HIPAA Privacy and Security standards at the forefront as we set up remote working environments in the home office setting. It is equally important to keep a healthy work-life balance in order to manage our time and stress levels effectively. This article will go over some key tips for managing both successfully. Under...

The daily news surrounding COVID-19 includes information and facts from those individuals who were diagnosed with COVID-19 but they now are in the recovery stage and have “Post-COVID-19” signs and symptoms. A recent study in Nature Medicine (March 22, 2021), titled, “Post-Acute COVID-19 Syndrome”, states the following: Acute COVID-19 usually lasts until 4 weeks from the...

If you have not heard yet, National Cancer Registrar’s Week (NCRW) is happening this week, April 5-9, 2021. We encourage you to join us by reaching out to your Cancer Registrar(s) to learn more about the work they do and to thank them for their service. This year’s theme, Cancer Registrars: The Driving Force of Cancer Data, underscores the role registrars expertly fill in...

Vaginal deliveries are the most common type of obstetric delivery, but there can be great variety among the diagnoses and procedures involved with these deliveries. Being familiar with pertinent ICD-10-CM and ICD-10-PCS coding guidelines and knowing a little about what the ICD-10-PCS character values for these codes represent will go a long way in helping you make...

A recent study was published in the Journal of the American Medical Association (JAMA) on March 22, 2021 titled, “Body Weight Changes During Pandemic-Related Shelter-in-Place in a Longitudinal Cohort Study”. This study takes a look at the impact of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or COVID-19 public health emergency (PHE) regarding “...

Risk Adjustment coding reviews can take many different shapes and forms. When starting a new project/review, there are many things to consider. A “Project Management” approach is key to success. Project Management includes four phases: Project Planning Phase; Project Build-up Phase; Project Implementation Phase; and Project Completion & Closure Phase. In this article we...

The first quarter of the American Hospital Association (AHA) Coding Clinic for 2021 has been released and contains the updated AHIMA/AHA FAQ on COVID-19 coding, as well as the January 1, 2021 update to the Official Guidelines for Coding and Reporting. In addition, this edition contains several ICD-10-CM coding questions and answers, and ICD-10-PCS scenarios to help with...

There is a Japanese proverb that says, “Vision without action is a daydream. Action without vision is a nightmare.” When cancer programs start establishing the quality initiative activities each year, they should set aside time to plan and explore proposed topics before launching into analysis or implementing solutions. Failure to take plan or methodically conduct a study...

The Program for Evaluating Payment Patterns Electronic Report (PEPPER) was developed in 2002 by TMF Health Quality Institute in support of CMS’ Hospital Payment Monitoring Program. State Quality Improvement Organizations (QIOs) began distributing PEPPER to the short-term acute care hospitals in their state in 2003. PEPPER provides provider-specific Medicare data...

The Centers for Medicare and Medicaid (CMS) MLN Matters recently published (2/25/2021) a provider compliance reminder regarding “Post-Acute Care Transfers”, often referred to as the PACT rule, and the correct coding and billing for these inpatient hospital claims. CMS quoted information from the recent Office of Inspector General (OIG) report which identified incorrect...

It is widely acknowledged that interventional radiology is one of the most complex medical coding specialties to master. There are many reasons why interventional radiology coding is so very challenging, but one of the main reasons is that many codes may be required to accurately capture all of the steps of a vascular procedure. To achieve success with interventional...

The Office of Inspector General (OIG) released a report on the concerns surrounding inpatient hospital stays with high levels of severity between 2014-2019. There was a reported 20 % increase found in the DRG (Diagnostic Related Group) severity levels, which are the most expensive and costly. The report was titled: “Trend Toward More Expensive Inpatient Hospital Stays in...

A January 27, 2021 research publication titled: Respiratory and Psychophysical Sequelae Among Patients With COVID-19 Four Months After Hospital Discharge, was released in the Journal of the American Medical Association (JAMA) with a focus on the post-acute phase of the SARS-COV-2 infection. We continue to hear and learn about a variety of COVID-19 sequelae, the type often...

When coding Angiography procedures in ICD-10-PCS, a number of variables can make it challenging to get the coding right. For instance, knowing what value a particular type of contrast maps to is necessary to assign codes accurately. To help you make correct character selections when coding angiography the information that follows provides a high level review of each...

Each year the Office of Inspector General (OIG) publishes their annual work plan for healthcare, which is a highly anticipated publication. The OIG Work Plan sets forth various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year. In addition, the OIG updates their workplan on a monthly basis, so their areas of...

We have now been familiar with the Hospital-Acquired Condition Reduction Program (HACRP) for seven years (how time flies). Under the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) reduces payments to hospitals based on their performance on measures of hospital-acquired conditions. The program encourages hospitals to implement best...

Elective surgeries were largely postponed or stopped entirely as the COVID-19 pandemic bore down on us. But as incidence and infection rates begin to taper off, the focus in many hospitals and surgery centers is turning to how they will “ramp up” to prepare for elective surgeries again. Understanding the current protocols, e.g., beds, testing, operating rooms (ORs) and...

Remote Patient Monitoring or RPM is expanding and expanding quickly. This type of technology can assist with the remote assessment and monitoring of chronic conditions such as, Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, Diabetes, Obesity, Hypertension, etc. This monitoring process allows for clinicians to address changes and/or concerns in the patient’s...

Across healthcare we focus on patient care and outcomes which is primary and foremost. In addition, we also focus on revenue and the revenue cycle. This will mean overpayments, which are compliance and financial risks and underpayments which are also both a compliance and financial risk. The American Hospital Association (AHA) released in January their annual report and a...

An issue was identified with the payment and cost sharing calculations on code G2025. Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) Claims with HCPCS code G2025 have been mass adjusted to correct the payment problem. Medicare Administrative Contractors (MACs) are reprocessing Federally Qualified Health Center and Rural Health Clinic claims with...

More than 600,000 people in the United States died from cancer in 2020 according to the American Cancer Society.   The National Cancer Institute (NCI) reported that an additional 10,000 deaths will occur in the next date due to pandemic-related delays in screening and treatment in patients diagnosed with breast and colorectal cancers. Given this we can ascertain that the...

Understanding the anatomy, physiology and disease process is a significant part of our daily work and competencies as Health Information Management (HIM) coding and Clinical Documentation Integrity (CDI) professionals. Thus, keeping on top of clinical information like that of Sepsis and COVID-19 is particularly important as it can certainly aid in determining when to...

February is National Cancer Prevention Month which promotes taking personal action to lower your risks for cancer. These include making healthy lifestyle choices for diet, exercise, avoiding tobacco products, protection against the sun as well as getting recommended cancer screenings and vaccinating against certain viruses that can cause cancer (e.g., human papillomavirus...

The American Health Information Management Association (AHIMA) and the American Hospital Association (AHA) have been publishing COVID-19 ICD-10-CM/PCS information and guidance since March 20th, 2020, last year. The most recent update occurred on March 1st, 2021 and is worth a detailed review. The COVID-19 coding FAQ (Frequently Asked Questions) covers both “CM”...

We are all hearing and seeing news and information daily about the efforts to vaccinate the United States population against COVID-19 and progress is being made. With this medical effort there is a wealth of published guidance and facts that have been developed by the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC),...

The words “Hierarchical Condition Categories” or HCCs can conquer up some anxiety for HIM Coding, and Clinical Documentation Integrity (CDI) professionals, even for Revenue Cycle and Compliance leadership. Add to that, the word “audit” and we now have uneasiness and even fear. Well, it does not need to be this way. Understanding the HCC basics and the coding audit ins and...

In a recent Journal of the American Medical Association (JAMA) a study on the highest reimbursed DRG (Diagnostic Related Group) trends from 2012 to 2016 was released. Medicare DRGs or Medicare Severity DRG (MS-DRGs) payment system includes the capture ICD-10-CM codes for complications and comorbidities which has a significant impact to disease severity, payment, and...

A recent medical research publication titled: International Classification of Diseases, Tenth Revision, Clinical Modification social determinants of health codes are poorly used in electronic health records; describes the underreporting of the Social Determinants of Health (SDOH) via ICD-10-CM (International Classification of Disease, Tenth Revision, Clinical...

You’ve got an education budget for 2021 and an entire team of motivated and knowledge-thirsty coders to teach. The challenging part? Choosing the topics. You need to choose wisely. After all, you’re taking coders out of a production environment for hours or even days at a time. Ideally, the information they glean is timely, immediately actionable, and relevant to your...

Coding Injections and Infusions for Chemotherapy Coding injections and infusions of chemotherapy agents often seems a little daunting, but understanding a few foundational definitions and principles can make code selection much easier. Read on to review the basics of injection and infusion coding that apply when reporting the administration of chemotherapy. Injections ...

The Centers for Medicare and Medicaid Services (CMS) has several programs they sponsor and/or support that target “improper payments”. One of those programs is Comprehensive Error Rate Testing or CERT. The purpose of CERT is to measure the Medicare Fee-For-Service (FFS) improper payments, which include Medicare Part A, Part B and Durable Medical Equipment and Suppliers....

Each year the Office of Inspector General (OIG) publishes their healthcare workplan and this is an “opportunity” for us in review and learn from their areas of focus. The workplan can be viewed at: Work Plan | Office of Inspector General | U.S. Department of Health and Human Services (hhs.gov) In addition, the OIG updates their workplan on a monthly basis, so focused...

The American Medical Association (AMA) released on January 19th, 2021 new CPT codes for the COVID vaccine administration and the vaccine by Johnson and Johnson, which is still pending approval by the FDA.  This COVID-19 vaccine was under development by Janssen Pharmaceutica, a division of Johnson & Johnson. The new CPT codes are: 91303    Severe acute respiratory...

A new OIG (Office of Inspector General) report has been released that is important to review. The title is: CMS and Its Contractors Did Not Use Comprehensive Error Rate Testing (CERT) Program Data To Identify and Focus on Error-Prone Providers (A-05-17-00023). See the OIG summary information below:    OIG Report: CMS and Its Contractors Did Not Use Comprehensive Error...

Many cancer patients encounter challenges that can delay or prevent them from receiving timely or appropriate care. In our current health care environment navigating cancer care services has become increasingly complex. Despite progress that is made to expand access, there are still gaps in the delivery system. The patient’s knowledge and understanding of their diagnosis...

New Synoptic Operative Standards Paving the way for Updated Best Practices of Cancer Care. Introduction Medical record documentation is an essential component to ensuring patient safety and quality of care in oncologic surgery. Surgical procedures are usually documented in narrative operative reports which are subjective and may lack important information. There is a...

Four Factors Affecting the Post-COVID Cancer Care Landscape by  Lijo Simpson, MD Like many healthcare providers, my practice at Atlanta Cancer Care has seen significant changes in most areas due to the COVID-19 pandemic. When the virus emerged earlier this year, we had to move fast to ensure our patients were protected from infection while delivering the best possible...

We have all been keeping up with COVID-19 and the code and guideline changes that have evolved since original coding advice came out in February of 2020. The advent of code U07.1 was a “game changer”. This code was created and made effective after April 1, 2020. The coding directive in this code states: Use additional code to identify pneumonia or other manifestations. ...

Coding Spinal Fusion: PCS vs. CPT When circumstances call for coding the same procedure in both CPT and ICD-10-PCS, a number of variables can make it challenging to get the coding right. For instance, the rules and guidelines that dictate whether an accessory procedure is integral to the primary procedure or separately reportable vary with the type of codes you are using.

OBSTETRICAL INPATIENT DIAGNOSIS CODING – A REFRESHER Obstetrics is to coding as cats are to animal lovers, you either love or dislike that subset of coding (or the animal kingdom) and there's no in-between. Sometimes a refresher of the highlights related to obstetrical coding can be beneficial for ensuring accurate coding for this type of record or even re-ignite an...

Finding a Career in Medical Coding Choosing Coding for a Career The demand for medical coders is growing. In fact, the Bureau of Labor Statistics expects this field to grow by 22% through 2026, and it's not a coincidence. Coding is a great career choice for anyone who wants to be in a non-patient facing position within the healthcare industry. It also offers the benefits...

When a provider addresses additional conditions at a general examination visit, usually referred to as a Well-Child or Adult Physical encounter, coders are often left to decide whether to assign a “with” or “without” abnormal findings code. So, how can we easily decide which code to assign? Per Coding Clinic First Quarter 2016 “For the purpose of assigning codes from this...

2021 CPT Code Updates It’s the most wonderful time of the year…annual CPT code updates! Who doesn’t love a good code update, right? Well, for 2021, AMA gives the people what they want with the release of 329 changes to CPT as outlined below and all changes going into effect January 1, 2021. · 206 new codes · 54 code deletions · 69 code revisions Keep reading to get a...

COVID-19 Related Coding Audits How Audits in the time of COVID are effecting healthcare institutions. In healthcare, audits, no matter how unpleasant they are, come with the territory. However, with the advent of the COVID-19 outbreak, audits have taken on a whole new level of dreadfulness. Read on to explore subjects related to the combination of Medicare’s medical...

To Code or Not to Code? That is the Question. Diagnostic Angiography with Therapeutic Interventions Stacie L. Buck, RHIA, CCS-P, RCC, RCCIR, CIRCC: President & Senior Consultant, RadRx One of the most common inquiries I receive about interventional radiology procedures is how to determine when to code for angiograms performed during the same session as a therapeutic...

Coding for pneumonia continues to be problematic for most coders. There are many types of pneumonia and documentation is often insufficient for coding to the level of specificity available in our current ICD-10 structure. Some of the specific types of pneumonia codes available include aspiration, bacterial, lobar, pneumonia due to influenza, ventilator associated...

5 Tips to Provide Effective Post-Audit Education You’ve identified high-risk areas based on previous audits or the OIG Work Plan. Or perhaps you decided to audit new service lines or high-dollar as well as high-volume procedures. You’ve selected a random sample of claims. You’ve audited those claims to determine coding and documentation accuracy. Now what? It’s time to...

Coding COVID-19 Infection in Newborns With the 2021 updates to the ICD-10-CM code classification came 14 new chapter specific guidelines. All but one of these guidelines is related to the coding of COVID-19 infection. Needless to say, COVID-19 is a big deal, and getting the coding for this condition correct has implications for both payment considerations and statistical...

October is Breast Cancer Awareness Month  Breast cancer is the most common cancer in women in the world and the second leading cause of cancer death in women. Breast cancer can be developed at any point in someone’s life, though the risk increases with age. On average, breast cancer takes the life of an American women every 13 minutes, and another case of breast cancer...

  When are your Cancer Registry Reporting Deadlines? The job of a cancer registrar is to collect and report data of cancer patients — capturing a full summary of the patient journey, from genealogical history to test results and treatment. This data is stored in hospital and healthcare facility registries and then reported to the central or state cancer registry as...

This article will provide some key points on how you can incorporate the current Office of Inspector General (OIG) items and future items into your organization’s auditing and monitoring functions. Paying attention to what the OIG for Health and Human Services (HHS) plans to audit and monitor during the upcoming year should be a one of the key drivers in developing your...

  From Cancer Registrar to Cancer  Patient When I graduated from Long Island University, I had earned my bachelor’s degree in Medical Records Administration and Management. Just as every other graduate with a degree, I was thinking I would be a director of HIM right out of the gate. Naturally, that did not happen. My actual first job was as a part-time unit secretary for...

Read parts 1 and 2 of this blog for more information about ICD-10-CM and ICD-10-PCS updates. FY 2021 Coding Guideline Updates:  The past two weeks we have discussed the ICD-10-CM and ICD-10-PCS coding changes effective October 1st, 2020. This week we will be reviewing any corresponding FY 2021 Coding Guideline Updates that are new or revised because of the annual coding...

ICD-10-PCS FY 2021 Updates Read Part 1, ICS-10-CM Coding Updates Here. as well as Part 3, Coding Guideline Updates, Here  The ICD-10-PCS update for FY 2021 will go into effect on October 1, 2020 and will cover patient discharges occurring from October 1, 2020, through September 30, 2021. This year’s updates include the addition of 544 new codes. There are no deleted, nor...

Read parts 2 and 3 of this blog for more updates on ICD-10-PCS and Coding Guideline Updates. ICD-10-CM Coding Updates effective October 1, 2020 (FY 2021) It is that time of year when the ICD-10-CM and PCS changes are right around the corner. Set to take effect on October 1, 2020 there are numerous updates to Official Coding Guidelines, ICD-10-CM, and ICD-10-PCS. Medical...

What is Cancer Registry? Cancer is the second leading cause of death among Americans. In 2019, there was an estimated total of 1,762,450 new cases of cancer in America and an estimated 606,880 deaths. Cancer registries receive and collect data about cancer patients. There are two major types of cancer registries: population-based registries and hospital-based registries....

When coding podiatry procedures one of the most valuable tools you have is an anatomy chart. Understanding exactly where the provider is, what bones, ligaments and tendons are involved, will help you select your CPT and diagnosis codes. At times finding CPT codes thru an encoder can be challenging. Don’t be afraid to crack open the ol’ CPT book and peruse the related...

    MRA is devoting itself to the pursuit of Health and Wellness within our communities. In late June, the CDC released a study revealing that 2 in every 5 American adults are currently struggling with mental health or substance use.  In fact, the study confirmed that “Overall, 40.9% of respondents reported having at least one adverse mental or behavioral health...

Internal coding audits are an important tool in any hospital’s compliance program. They illuminate potential areas for corrections prior to scrutiny by payers and regulators, which can help reduce payer denials and protect revenue. Additionally, performing regular, ongoing internal auditing can improve clinical documentation and coding initiatives, enhance data integrity,...

During this time of year in the coding world we are preparing for the October 1st ICD-10-CM and PCS coding updates, but we were recently surprised with an announcement on July 30th from The Centers for Medicare and Medicaid (CMS). Twelve new ICD-10-PCS procedure codes concerning Covid-19 therapeutics became effective August 1, 2020.  Per the CMS website announcement on...

Outpatient Clinical Documentation Improvement/Integrity is gaining more and more attention. Having a successful program involves preparation, planning and executive. As we discussed in Part I (in the previous RMC newsletter) there are several key components to an OP CDI program. A best practice is to identify one setting that you wish to focus your CDI program on to...

The National Cancer Registrars Association (NCRA) has released a 2020 report on their Outsourcing and Perception Survey which was conducted and analyzed by Association Research, Inc. Click HERE to see the survey report in totality.   The study explains in greater detail industry perceptions of cancer registry outsourcing and sheds light on the ramifications of...

E/M office and other and other outpatient visit guidelines will be changing as of January 1, 2021. Below are further details regarding these changes: Read Part I and Part II of this blog for more information. Major E/M revisions for 2021 regarding time of patient encounters include Extensive E/M guidelines additions, revisions, and restructuring Deletion of code 99201...

Coding for pneumonia continues to be problematic for most coders. There are many types of pneumonia and documentation is often insufficient for coding to the level of specificity available in our current ICD-10 structure. Some of the specific types of pneumonia codes available include Aspiration, bacterial, Lobar, pneumonia due to influenza, Ventilator Associated...

Conducting regular audits of your coding and billing procedures is a great way to identify and eliminate upcoding and incorrect coding incidences within your practice. In a recent article from Becker’s , it is estimated that hospitals overbilled Medicare by $1 billion from inaccurate coding. The office of Health and Human Services (HHS) Office of Inspector General cited...

When you are considering the pros and cons of a variable vs fixed cost structure, don’t overlook certain specialty areas such as registries. For example, On April 2, 2020, the American College of Surgeons (ACoS) sent out a newsletter stating that ACS Accreditation and Verification Programs have been granted an extension of one year for hospitals currently accredited and...

There are several cardiovascular diseases that contribute to death in the United States and also are the leading cause of death. According to the Centers for Disease and Control (CDC), 1 in every 4 deaths are due to heart disease. The most common cardiovascular disorder is coronary artery disease (CAD), and in fact a heart attack or myocardial infarction (MI) occurs every...

A compliance task that each facility should perform to support the Health Information Management (HIM) department is performing coding audits. Coding audits are performed to access the accuracy of the diagnosis and procedures codes assigned to each patient’s chart. The timing of these audits can be performed monthly, quarterly, bi-annually, annually, or as often as the...

With our E/M office or other outpatient visits guidelines changing on January 1, 2021, below are the details explaining the changes. Read part 1 of this article HERE.   Choosing the correct E/M level beginning January 1, 2021 is based on:  The level of medical decision making (MDM) as defined for each service; or  The total time for E/M services performed on the date of...

With more and more patient services moving to the outpatient setting we need to be ready and prepared for the implementation of an outpatient (OP) Clinical Documentation Improvement/Integrity (CDI) program. CDI has a strong footprint in the inpatient hospital setting where there are longer periods of time of patient interaction, longer time to review the health record and...

It has been almost 30 years since evaluation and management (E/M) office visit documentation and coding has been changed.  These changes take place beginning January 1st, 2021.  The revised guidelines will improve documentation redundancy and support medical necessity.  In the past, the code selection was based on 3 key elements (history, examination, and medical...

As we continue to feel the impact of COVID-19 in the United States and continue canceling meetings to avoid travel and risks of exposure, many families are also concerned about their loved ones currently going through cancer treatment.  And many others are currently being diagnosed with cancer during this worldwide pandemic.  The big question is how does this impact...

Small physician practices may find themselves challenged when managing a practice that has to address billing issues with payors, the adoption of complex workflows, and staying aware of all rules and regulations (Adler, 2015). Developing a Compliance Program may feel like a large task, but a Compliance Program can be an important tool for physician practices of all sizes...

The current pandemic has prompted the World Health Organization (WHO) to take the unusual step of establishing a unique ICD-10 code for COVID-19 cases, U07.1 five months prior to the traditional U.S. implementation date for new codes. The use of the code became effective with April 1, 2020 discharges and was accompanied by updated coding guidance to the ICD-10-CM Official...

What Does CMS Say?  Congress passed wavier 1135 that states Medicare and other commercial carriers have temporarily expanded services for reimbursement on several telehealth services.  Click here for list of covered services during this Public Health Emergency (PHE) due to COVID-19.  For additional information on COVID-19, click here.  CMS is now releasing News Alerts...

Do you know the difference between a CVA and TIA? When coding cerebral vascular accidents (CVA) and transient ischemic attacks (TIA), it is important to know the difference between the 2 diagnoses as well as the different types of CVA. While both a CVA and TIA are caused by blockages to the arteries of the brain, a CVA is a more serious condition and can cause permanent...

Making changes on the fly is never easy in any industry, especially healthcare - figuring out what platform to use, training staff and patients on how to operate video conferences, but more importantly, will you get paid? With the Corona Pandemic turning our revenue cycle upside-down due to the cancelling of most elective procedures, it’s more important than ever that we...

In this environment it’s hard to know what tomorrow will bring. If you watch the news, all you’ll see is a lack of hospital beds and overwhelming patient volumes. Meanwhile, hospitals and clinics around the country are laying off staff because elective and non-emergent procedures have been cancelled to clear the decks for COVID patients. To add to the complexity, many...

Coding diagnoses from ICD-10-CM, Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders, does not prove to be an easy task. Psychiatry and mental health professionals use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) for applying diagnoses, which does not always correspond equally to codes from ICD-10-CM, and it is up to the...

There were 6 codes deleted for 2020 and 9 new codes were added under the Health Behavior Assessment and Intervention section. These family of codes were first established in 2002. With increased awareness and need for these types of services there was a need for more code revisions. Codes 96150-96155 have been deleted and replaced with the new codes 96156, 96158, 96159,...

There are many procedures that are done to the nose, including turbinate resection, repair of nasal vestibular stenosis, septoplasty, endoscopic sinus surgery to name a few. These can be tricky to code in CPT, and documentation of course is key. Turbinate hypertrophy can cause an altered sense of smell, dry mouth, nasal congestion, facial pain and snoring. This can be an...

By Marianne Loeffler, COC, CPC, CPC-I, CRCR, MRA Charge Audit Validator Infusions & Injections are confusing – even on a good day. Facilities often leave money on the table – and a lot of it – simply because knowledge and resources may be limited.  This article will briefly discuss the key elements to be aware of when reviewing documentation to accurately code injections...

  Transcatheter Aortic Valve Replacement (TAVR) is also known as Transcatheter Aortic Valve Implantation (TAVI). Medicare officially refers to this as TAVR/TAVI, but either single acronym is correct. TAVR is a transcatheter surgical procedure in which an aortic valve replacement is performed without removing the damaged native valve. In simple terms, it is similar to...

The FY 2020 IPPS final rule was released by the Centers for Medicare and Medicaid (CMS) on August 2, 2019.[1] Below are five highlights to be aware of regarding changes to ICD-10-CM, ICD-10-PCS, and corresponding official guidelines in FY 2020. ICD-10-CM[2] Effective October 1, 2019 there are 273 new ICD-10-CM codes, 21 deleted ICD-10-CM codes and 30 ICD-10-CM code...

MRA and YES HIM Consulting have partnered to delivery coding education to healthcare organizations across the United States. For over 30 years, MRA is known for delivering operational efficiency, service excellence to organizational integration to Revenue Cycle, HIM, Compliance and Cancer Registry areas in healthcare organizations. YES HIM Consulting is a premier Health...

Do you ever feel like by the time your organization and coders get used to one regulation, the rules change?  These frequent changes and the rapid pace of healthcare technology and trends make it critically important to ensure compliance and ongoing training and education is provided for coding professionals.  Judging from the sheer volume of codes can be...

MRA is known for delivering operational efficiency, service excellenceto organizational integration to HIM, Compliance and Cancer Registry areas in healthcare organizations. MRA continues to drive expansion by adding Mike Hodgson to the Senior Management team as Executive Vice President, Sales and Marketing. Mike Hodgson has served in various executive positions...

Working in cancer registry is a tough job. Most hospitals see a diverse patient population. A registrar needs to accurately summarize each cancer patient’s history, diagnosis, treatment, and health status while following mandated guidelines. This requires analyzing and synthesizing information from many different resources. Registrars provide critical data that is used...

Internal coding audits are an important tool in any hospital’s compliance program. They illuminate potential areas for corrections prior to scrutiny by payers and regulators, which can help reduce payer denials and protect revenue. Additionally, performing regular, ongoing internal auditing can improve clinical documentation and coding initiatives, enhance data integrity,...

Simply mentioning a coding audit sends a shiver up a coder’s spine. The thought of scrutinizing their coding quality, as they strive to balance quality and productivity, can bring dread to even the most seasoned coder. But conducting internal or external coding audits are an important part of ensuring quality and regulatory compliance for hospitals and health systems....

  As we discussed last week, over the past decade, there has been a tremendous amount of consolidation in healthcare. For hospital-owned physician practices specifically, we have seen the number  rise from 35,700 in July 2012 to 80,000 in January 2018. Over the same period, there was over a 70 percent increase in the number of physicians employed by hospitals or health...

  One of the key trends to emerge from last month’s JP Morgan Healthcare Conference was the shifting mindsets of hospitals. For the last decade, hospitals have had a defensive mindset; acquiring or merging with smaller hospitals and physician practices to outpace their competitors and grow top line revenue. But to receive the full payoff of this consolidation, hospitals...

In coding, like most every other area of life, there is not one solution for every organization’s potential problems. Coding is an ever-expanding area of focus for most every healthcare organization, and nearly every health system and the facility has or is making substantial investments in coding staffs and making these departments more robust. There are hurdles and...

Preparing For the Upcoming Cancer Registry Changes: Time Is Short, but Support is Available By Susan Mackenzie, MRA For those of us working in the cancer registry profession, you are likely very much aware of the significant changes upon us that will dramatically alter the way we work and how we collect required data for the registry. The upcoming changes are extensive,...

One of the more prominent guidelines found in the ICD-10-CM Official Guidelines for Coding and Reporting is Section III. Reporting Additional Diagnoses but it isn’t always applied appropriately. The guideline states: For reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:clinical...

The Centers for Disease Control and Prevention (CDC) recently published its ICD-10-CM code changes for the fiscal year 2019 that take effect Oct. 1, 2018, and run through Sept. 30, 2019. In this annual update, there are 473 code changes, including 279 new codes, 143 revised codes and 51 de-activated codes. Additionally, 39 other changes were made from the proposed rule. ...

Recently, we’ve had a number of conversations with healthcare leaders concerned about their evaluation and management (E/M) coding levels being out of synch with Centers for Medicare and Medicaid Services (CMS) guidelines, and who wanted to review their processes to ensure compliance. Concerns over whether coding departments (if not outsourced) are properly notating the...

Let’s first look at what a Swan-Ganz Catheterization is and how the procedure is performed. The Swan-Ganz catheter is synonymous with a pulmonary artery catheterization. It was named in honor of its inventors who were Jeremy Swan and William Ganz from Cedars-Sinai Medical Center in 1970. It is a flow-directed catheter with a balloon tip that is inserted via an internal...

The HITECH Act (The Health Information Technology for Economic and Clinical Health) was enacted as part of the American Recovery and Reinvestment Act of 2009. The law was created to promote the “adoption and meaningful” use of health information technology. The Act instructed the Secretary of HHS to strengthen an individual's access rights in important ways. One way is by...

The pace of change, consolidation, and ever-increasing pressure on revenue and financial stability in the healthcare industry is enough to make our heads spin on a daily basis.  Couple that with the onslaught of government and commercial payer audits and denials, it’s no wonder healthcare organizations are in denial about the state their denials.  Feeling overwhelmed and...

Heart failure is a serious medical condition that an estimated 5.7 million Americans are diagnosed with.  This is a condition that occurs when the heart muscle cannot pump enough blood and oxygen needed by the body to support the other organs.  According to the Center for Disease Control, the national estimated cost to treat heart failure is nearly $31 billion each year. ...

With the OCR issued FAQs on patient HIPAA rights to access PHI being out now for over a year, I know many of you are feeling more confident than ever on how to handle these pesky third party requestors who demand records under the HITECH Act. Or perhaps you are just as challenged as the rest of us? The FAQs clarified that individuals (patients according to HIPAA...

Overweight and obesity are increasingly common conditions in the U.S. They are caused by the increase in the size and amount of fat cells in the body. Doctors measure body mass index (BMI) and waist circumference to screen and diagnose overweight and obesity. The National Institute of Health has deemed obesity as a serious medical condition that can cause complications...

The regional treatment modality fields for radiation therapy can be tricky when deciding on the appropriate code to assign. The regional treatment modality field is used to record the dominant modality of radiation therapy used to deliver the most clinically significant regional dose to the primary volume of interest during the first course of treatment. Codes are...

Electronic Health Records (EHRs) continue to change the landscape of healthcare.  Although the technology and workflow of electronic documentation seems to make paper documents obsolete, a hybrid medical record exists in many healthcare settings.  Organizations need to determine which paper documents to include with the EHR, access to that documentation and when to...

A 67 year old male who had been experiencing frequent melena presents to the hospital for work up and treatment. An esophagogastoduodenoscopy (EGD) was performed with the finding of a medium sized angioectasia (AVM) seen in the mid jejunum which was thought to be the source of the bleeding. As a result, the following procedure was performed: A single medium angioectasia...

As we evolve in 2017, the challenges have settled for Health Information Management (HIM) post implementation of ICD-10.  Clinical Documentation Improvement (CDI) programs and Computer Assisted Coding (CAC) continue to bring value to data integrity.  Larger healthcare systems continue to centralize revenue services while their auditing efforts have improved with...

  There are a variety of conditions that can impact individuals with diabetes.  People with diabetes are at greater risk for developing eye problems that could lead to blindness or serious deterioration of sight.  Age also plays a role in the progression of eye disease in individuals with diabetes.  Cataracts, glaucoma and retinopathy are the most common eye diseases that...

March is kidney cancer awareness month. So what is the role of our kidneys? The kidneys are bean shaped organs located on each side of the mid back. The kidneys are retroperitoneal organs that lie behind the peritoneum that lines the abdominal cavity. The main function of the kidneys are to filter the blood and get rid of excess water and waste in the urine. However, did...

What are the most significant challenges for Health Information Management (HIM) departments?  One of the challenges in 2016 includes the disappearing HIM department; physical downsizing as well as workforce downsizing.  With the workforce downsizing we see technology impacting traditional roles for transcriptionists, documentation specialists and coders. HIM...

A sixty-nine year old male is admitted with severe abdominal pain and is found to have diverticulitis. He undergoes an open sigmoidectomy with pathology report revealing a peridiverticular abscess. The patient has other secondary conditions such as COPD, hypertension, Stage II chronic kidney disease, hypothyroidism and GERD. The coder codes K57.32 for the diverticulitis...

One challenging coding area with the ICD-10 transition is the coding of venous and arterial lines and catheters. This article aims to provide greater clarity with regard to procedure coding tips for coding of venous catheters. Types of Lines: Central Lines- (CVC)- Central Venous Catheter or central lines are inserted into large veins, typically the jugular, subclavian,...

Cancer registries are legislatively mandated to collect confidential data on tumor characteristics, monitor cancer trends, aid in epidemiologic research, and collect quality cancer data elements. Abstracting Timeliness and what this means to you: Abstracting timeliness entails the completion of all analytic cases within six months from the date of initial diagnosis must...

The Growth In HIM Roles In just 10 short years, the times have changed and with those changes the challenges facing today’s healthcare organizations are impacted by the speed of technology and continued decreasing revenue margins. When we think back to Health Information Management (HIM) Departments a decade ago, we were focused on managing a medical record that was...

Medical Coding Outsourcing We live in a constantly expanding environment for outsourcing services, and the coding and health information industry is no stranger to outsourcing. Whether it is full department outsourcing, hand-picked silos of outsourcing for specific hard to fill or hard to train services or outsourcing to augment your current staff, utilizing contract...

Organizations did a fantastic job preparing for ICD-10. However, now that the dust has settled, we need to drill down into the data. Specifically, case mix index (CMI). With more than two months’ worth of ICD-10 data, it’s easier to make comparisons and draw logical conclusions. If coding and/or documentation problems exist, they’re likely starting to emerge through your...

As a cancer registrar, ask yourself this question: Have you ever been involved in a lengthy discussion about the use of Class of Case 00 vs. 10? Is it frequently difficult to determine which Class of Case is more appropriate?  If you answered “yes” to either or both of these questions, you are not alone. Setting The Cancer Registry Stage   Before we dive more deeply into...

In a previous post, I discussed the healthcare industry’s transition from a volume-based reimbursement system toward a model that is quality driven.  How can organizations ensure that they’ll succeed in this increasingly pay-for-performance environment? One way is to explore shared-risk contracts in non-revenue generating areas of the hospital.  shared risk model allows...

This past September, I had the privilege of attending the AHIMA annual convention in New Orleans. I was particularly looking forward to presentations on information governance and ICD-10. Not only was I able to learn more about both of these important topics, but I also learned about several other initiatives that will surely affect the HIM profession going forward. ...

The following Latin proverb seems to be particularly relevant in light of ICD-10: “Times change, and we change with them.” By now, ICD-10 has spurred many changes in technology, templates, coding, documentation, and more. However, to be truly successful, organizations must look beyond their HIM internal processes and ask this question: Must the organization’s relationship...

In today’s value-based healthcare marketplace, pay-for-performance initiatives are everywhere you look. There’s the CMS Hospital Value-Based Purchasing program, the Physician Quality Reporting Program, public quality reporting websites (e.g., HealthGrades® and Hospital Compare), the proliferation of Accountable Care Organizations (ACO) nationwide, and Meaningful Use....

Cancer Registry Data A cancer registry abstract provides a quick glimpse into each patient’s unique story. As part of this abstract, coded data provides specific details about the cancer, such as the disease process or specific treatment that patients undergo in each facility. However, to paint a complete picture, coded data must be supplemented by text. Cancer registrars...

Unfortunately, the silos between coders and CDI professionals still exist in many hospitals. In some organizations, the walls may be slowly coming down, but in others, the silos stand tall. The irony is these two roles actually have more in common than they might realize. With communication and collaboration, coders and CDI specialists actually have the power to make a...

As the ICD-10-CM/PCS deadline approaches, it behooves HIM professionals to remind CDI specialists and physicians about important components of a thoroughly-documented operative note. Such a note supports accurate code assignment for reimbursement, and it also provides an accurate record for continuity of care as well as quality initiatives and legal and research purposes.

As one of MRA’s new recruiting specialists, I wanted to take this opportunity to introduce myself and share some information about my experience in the HIM profession. With 15 years of recruiting experience, I’m thrilled to be a part of MRA’s team. It’s a pleasure to recruit for HIM positions. HIM professionals are very enthusiastic about the work they perform. HIM is a...

Standards 5.3 and 5.4 of the American College of Surgeons’ (ACoS) Cancer Program Standards 2012, Version 1.2.1: Ensuring Patient-Centered Care require cancer registries to perform follow-up for 80%–90% of analytic cases. This includes recording vital status, cancer status, and date of last contact. Although cancer registry follow-up guidelines exist, these guidelines are...

Combat ICD-10 Information Anxiety Anxiety is always tough to combat, and with the implementation of ICD-10 quickly approaching, coders’ anxiety levels may be at an all-time high. The entire journey has been a rollercoaster, making it difficult to manage emotions and prepare mentally for a go-live date that has essentially been a moving target. Although the House of...

Continued Education For MRA Employees In a previous blog, I discussed the advantages of working remotely and how this arrangement can enhance one’s work-life balance. In this article, I’ll focus on another way in which employees can find purpose and meaning in their chosen careers—that is, enhancing one’s knowledge and education. At MRA, employees have found continuing...

Health Information Management Professionals Thirty years ago, an HIM professional often worked in a windowless basement of a hospital sorting through piles of paper records, filing loose forms, and flipping through a rolodex-style master patient index (MPI). Employers looked for individuals who could alphabetize and organize. The HIM profession was largely unknown within...

Remote Clinical Documentation Improvement Coding There’s no doubt that remote work has its perks for employers—increased productivity, lower overhead costs, and a better pool of candidates from which to choose. We explored the benefits of remote work options in a recent blog topic here. However, in a virtual world, the nuances of good old fashioned face-to-face...

More than 140,000 people are diagnosed with colorectal cancer every year, according to the Center for Disease Control and Prevention (CDC). More than 50,000 die from the disease annually. What’s worse is that colorectal cancer is the second leading cause of cancer deaths in the United States. More than 90% of colorectal cancers occur in individuals over the age of 50. ...

In a previous blog, I discussed the pros and cons of working with a contract HIM firm. Now I’d like to dive into the advantages of working remotely and how this arrangement can enhance one’s work-life balance. Picture this: You wake up in the morning, pour yourself a cup of coffee, and embark on your commute to work—that is, you take the 10 or 15 steps from your kitchen...

Flu During Peak Season It’s that time of year again—flu season. According to data from the Centers for Disease Control and Prevention (CDC), 43 states are experiencing high or widespread flu activity mostly due to the spread of the H3N2 virus. For the week ending December 27, 2014, visits for influenza-like illness accounted for 5.9% of all clinic visits. During this same...

Each of us has the power to change our lives as well as the lives of those around us. This is the theme of a recent article I read by Jeff Haden titled 19 Things Remarkable People Think Every Day. The article, which was published on Inc.com, includes a lot of salient points that are relevant to HIM professionals. My favorite point that Haden mentions in the article is,...

Medical Coding Contract Jobs Remote coding job opportunities have increased significantly over the last several years, and these opportunities show no signs of slowing down. The number of all professionals who work remotely (including those in the medical and health sector) grew by 118% last year, according to an analysis by FlexJobs. Those specifically in the medical and...

Chemotherapy is one of many treatment options for patients with cancer. This form of therapy uses chemical agents (i.e., anti-cancer or cytotoxic drugs) that interact with cancer cells to eradicate or control the growth of cancer. Common alternative forms of treatment include surgery to remove all or a portion of a tumor as well as radiation therapy, hormone therapy, and...

Although CDI programs have typically been implemented in the inpatient setting, many organizations are beginning to turn their attention toward outpatient documentation as well. That’s because many of the same documentation deficiencies occur in both settings. Poor outpatient documentation—particularly in the emergency department (ED) record—can also affect inpatient code...

HIM Outsourcing Our industry’s transition to EHRs has opened new doors for health information management (HIM). HIM’s operational areas have become more specialized than ever. The result? Many healthcare executives are now able to reduce expenses, reallocate staff and free up space through centralization and remote workers. According to a recent HealthLeaders CFO Forum,...

In today’s electronic world, coders have a variety of technology tools to make their jobs easier. These applications boost coder productivity while also improving code quality and accuracy. With the inevitable implementation of ICD-10, the reliance on coding technology will become even more prevalent—and important. Here are key coding resources every coder should be...

Jack and Suzy Welch suggest that most of us are confused about innovation. They state, “You’re getting innovation all wrong. Innovation is a series of little steps that cumulatively lead up to a big deal that changes the game.” When it comes to HIM and EHRs, I believe they are absolutely correct. The EHR was “a big deal that changed the game” for healthcare providers....

Why QOPI Programs Matter Quality Oncology Practice Initiative programs are designed for hematology-oncology physician-based practices. Strictly voluntary, QOPI programs provide a valuable tool to assess current practice standards. QOPI Methods and Measurement Chart abstraction is performed twice a year, spring and fall, and covers a five week period. During this...

The shift in roles, responsibilities and reporting structures for Health Information Management (HIM) professionals is top of mind for healthcare revenue cycle and finance executives as we enter 2015. What lies ahead for HIM and their relationship to revenue cycle? Here are three trends for healthcare finance executives to consider. 1. Shift Coding to Revenue Cycle /...

Ann Dooley, RHIA, Director of Disclosure Management The iPhone 6 was released a couple weeks ago and Apple lovers around the world rejoiced. The new model includes advanced technology and improvements to the last version. But there’s a problem. The iPhone is breaking in half, partly because of how it’s being used and cared for. Similar to the iPhone challenge is the...

Role changes are on the horizon for coding professionals. With the implementation of Computer Assisted Coding (CAC), ICD-10 and Hospital Value-based Purchasing (HVBP), clinical coding will take on different forms and new responsibilities. Traditional coding careers may transition to auditors, data analysts or even clinical documentation improvement / integrity specialists...

Mycosis fungoides (9700/3), also known as Alibert-Bazin syndrome, is the most common type of primary cutaneous T-cell lymphoma.  The name Mycosis fungoides loosely means “mushroom-like fungal disease.” It is so named because the skin tumors, particularly of severe cases, have mushroom-like appearance.   However, it is not a fungal infection but rather a type of...

Ignore HIM at Your Own Risk Medical records are going electronic at record-breaking speed. Spurred by meaningful use incentives, EHRs are being rapidly installed and core HIM functions quickly automated. Many HIM functions are already outsourced and hospital leaders plan to offload even more HIM tasks in the year ahead. For example, a recent survey of 650 hospital...

How to Successfully Navigate Appeals Even with the temporary suspension of RAC reviews, hospitals continue to deal with insurance denials from a multitude of third party payers. Cathie Wilde, CCS Vice President of Coding Responding to these coding denials is time consuming. HIM, revenue cycle and coding professionals are further frustrated when they believe their...

Are you ready to report cancer cases diagnosed in 2014?  Summer brings races. Running races, bike races, boat races, and of course automobile races. While NASCAR and Indy Car drivers start their engines, cancer registries are revving up to report their 2014 cases.   Elizabeth Patena, M.D., CTR VP of Cancer Registry But before you start abstracting and coding cases...

Nothing is more dangerous than an incorrect code. Whether in ICD-9, ICD-10 or CPT, your organization’s coding practices must be ethical, complete, accurate and compliant. So how are you measuring coding quality today? Which of the following best practices do you use? Lynn Salois, RHIT, CCS, CDIP Director of Coding Perform periodic internal coding quality audits. ...

ICD-10 Implementation Process Every lesson learned is a step forward. This past week’s decision by the Senate certainly provided a few new lessons for hospitals. First and foremost, we are reminded to “never say never”. And secondly, we can now take a breath and contemplate how to respond. Serious questions now emerge for everyone. The first of these being, when will the...

Elizabeth Patena, M.D., CTR VP of Cancer Registry For cases January 1, 2010 and forward, Grade Path Value records the numeric grade reported in the pathology report. It documents the numerator or first number of a tumor grade reported in a two, three, or four grade system. It supplements but does not replace the data item Grade/Differentiation. Grade Path System...

Gastrointestinal stromal tumors (GIST) may occur anywhere along the entire length of the gastrointestinal tract (GIT), as well as in extravisceral locations, which include the omentum, mesentery, pelvis, and retroperitoneum. Typically, they arise from the wall of the GIT and extend inward toward the mucosa, outward toward the serosa, or in both directions. Lesions that...

Cathie Wilde, RHIA, CCS, Director of Coding Services Myocardial Infarction Coding Aside from the obvious code changes, a coder needs to be aware of some fundamental differences in guidelines for the coding of myocardial infarctions. The ICD-9 fifth digit designation of unspecified, initial episode or subsequent episode of care is no longer applicable The time frame...

Cathie Wilde, RHIA, CCS, Director of Coding Services On January 31, 2014 CMS extended the “Probe & Educate” review process for implementation of the 2-midnight benchmark for an additional 6 months through September 30, 2014. What does this mean? The 2-midnight benchmark is still the rule for FY 2014 in determining the patient’s admission status. However, through...

Lynn Salois, RHIT, CCS, CDIP, Director of Coding A unique friendship between coder and radiologist is on the horizon. It is actually not so unique, but rather very logical. ICD-10-CM fracture coding requires anatomical specificity, simply stated, which bone is broken and what part of the bone is broken? For example, fracture of subtrochanteric neck of the right...

  Elizabeth R. Patena, M.D., CTR Vice President of Cancer Registry   Distal Esophagus vs. EGJ When do you code the primary site to Distal Esophagus (C15.5) or Esophagogastric Junction (C16.0)? The arbitrary 10 cm segment encompassing the distal 5 cm of the esophagus and proximal 5 cm of the stomach, with the EGJ in the middle, is an area of contention. Cancers arising in...

Cathie Wilde, RHIA, CCS, Vice President of Coding Services The Office of Inspector General (OIG) conducted a study to determine to what extent hospitals that received electronic health records (EHR) Medicare incentive payments through the American Recovery and Reinvestment Act of 2009 (ARRA) had implemented recommended fraud safeguards for EHR technology. Two areas...

Elizabeth R. Patena, M.D., CTR Vice President of Cancer Registry For breasts cancer cases, should you count sentinel nodes as ipsilateral axillary nodes for data field CS SSF3 and CS SSF19? Here are my thoughts… Sentinel lymph node: the hypothetical first lymph node or group of nodes draining a cancer. In CS version 1, data field CS SSF3 was called Number of Positive...

Lynn Salois, RHIT, CCS, CDIP, Director of Coding Situation: Some to do list items appear more challenging than others, or so we think. For example, creating an environment of teamwork and collaboration amongst the Coding and CDS group may seem like a monumental task, but in reality, it can be very simple. Begin with fostering two basic core values: Communication and...

  Cathie Wilde, RHIA, CCS, Director of Coding Services   Anemia Sequencing Scenario: A 66 year-old patient was diagnosed with carcinoma of the upper third of the esophagus after an admission for workup due to severe fatigue and is undergoing outpatient radiation treatment prior to surgery. However, the patient is admitted today with shortness of breath episodes and was...

Elizabeth R. Patena, M.D., CTR Vice President of Cancer Registry Although this Standard is to be phased in for 2015, now is the time to prepare an action plan before the implementation in January 2015. What do you, as the Cancer Registrar, need to do to prepare for this Standard? Here are my thoughts… First, include the implementation of this Standard as one of your...

  Cathie Wilde, RHIA, CCS, Vice President of Coding Services   Sudden Cardiac Arrest Situation Situation: A 45 year old man is admitted to the ER in cardiac arrest, bradycardia and tinnitus. History indicates that he was having a minor procedure in the physician’s office when he developed cardiac arrest following injection of lidocaine in anticipation of the procedure....

Elizabeth R. Patena, M.D., CTR Vice President of Cancer Registry Three sets of new data items are added for 2013: Country, Secondary Diagnoses, and Over-rides for CS 1-19. In my last blog (read here) I discussed the new data item Country. Now we will focus on the new items that identify Secondary Diagnoses, and Over-rides for CS 1-19. Secondary Diagnoses: Federal...

  Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education   CMS has finalized a significant change to its inpatient admission guidelines as part of the 2014 IPPS Final Rule[1], released August 1, 2013. As presented in a recent MRA blog, the 2-Midnight Rule basics are: For an inpatient stay to be deemed medically necessary, the physician must expect...

Cathie Wilde, RHIA, CCS, Vice President of Coding Services Situation: In the CMS 2014 IPPS Final Rule[1] effective October 1, 2013, the criterion for inpatient admission has been redefined with the implementation of the “2-midnight” rule. This differs from the current 24 hour benchmark for determining inpatient vs. observation stays. With this policy change, CMS...

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding The multitude of changes in the healthcare industry are forcing hospitals to re-design and re-energize their Clinical Documentation Improvement Programs. To assist in this endeavor, HIM Directors and coding managers should examine the existing relationship between the two driving forces behind the success of...

Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education Scenario: The scenario is centered around a pediatric acute care setting and CPT codes 99468, 99471, 99475 – Initial In-Patient Neonatal Critical Care. When a patient transfers off of NICU or CICU to a regular medical floor but returns 7 days later for a complication, new problem or...

Elizabeth R. Patena, M.D., CTR Vice President of Cancer Registry Changes in 2013: What’s new in 2013? Three sets of new data items are added for 2013: Country, Secondary Diagnoses, and Over-rides for CS 1-19. For now, let’s focus on the new items that identify Country. The three new items that identifies country: Address at DX-Country Address Current-Country ...

Scenario: Cathie Wilde, RHIA, CCS, Vice President of Coding Services A twenty-five year old woman who is 34 weeks pregnant is admitted for mild pre-eclampsia. Treatment for pre-eclampsia is successful but during course of the admission the patient develops other pregnancy complications including thrombocytopenia, oligohydramnios and painful diastasis recti....

Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education Situation: We always strive for completeness of clinical documentation. It is important to remind providers and practice managers to heed a warning from an OIG initiative; the OIG has announced their intent to audit healthcare organizations receiving meaningful use payments as part of the...

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding Discharge diagnoses listed in the discharge summary are pneumonia and sepsis present on admission. The diagnostic statement of pneumonia is documented throughout the medical record. However, the diagnostic statement of sepsis is a one time diagnostic statement in the discharge summary only. If in fact, both...

Situation: Elizabeth R. Patena, M.D., CTR Vice President of Cancer Registry 78 y/o female admitted for vague abdominal pain and increasing abdominal girth. Initial imaging work-up revealed bilateral adnexal masses, right larger than left. No significant pelvic adenopathy. Laparoscopic right salpingo-oophorectomy revealed poorly differentiated Sertoli-Leydig cell...

Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education Situation: Many facilities have had payments retracted by a payer over a non-attested or unsigned operative report. This is easily overlooked but should be on the priority list to ensure a service, be it an operative or clinic encounter (E/M), is in fact, billable, can come down to the...

Scenario: Cathie Wilde, RHIA, CCS, Vice President of Coding Services A 56 year old male presents to the emergency room with alcohol withdrawal after discontinuing alcohol 24 hours prior to presentation. He is placed on CIWA protocol and admitted to the hospital. The attending physician notes in the history that the patient has a diagnosis of alcoholism for over...

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding Let’s begin with two very important ICD-10 readiness true or false questions: Question 1: True or false -Today’s coding professionals will be ready for the ICD-10 transition? Question 2: True or false –Physician documentation will include the necessary detail for accurate and specific ICD-10 code assignment?

Situation: Elizabeth R. Patena, M.D., CTR Vice President of Cancer Registry Cytology is an examination of cells (rather than tissue) including but not limited to: sputum smears, bronchial brushings, bronchial washings, prostatic secretions, breast secretions, gastric fluid, spinal fluid, peritoneal fluid, pleural fluid, urinary sediment, cervical smears, or vaginal...

Situation: Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education A physician’s office notices a significant loss in revenue in relation to critical care services. What is causing this and what can be done on the HIS side to remedy the issue? Here are my thoughts… Time Capture: Problematic for many providers is remembering what to include in...

Situation: Cathie Wilde, RHIA, CCS, Vice President of Coding Services A 21 year old female is admitted to the hospital with abdominal pain. Testing reveals patient with pelvic inflammatory disease (PID), bacterial vaginosis and a positive pregnancy test. History reveals the patient was sexually assaulted 3 weeks prior and PID likely related to that incident. The...

Situation: Elizabeth R. Patena, M.D., CTR Vice President of Cancer Registry A patient with a history of Stage IB Diffuse Large B-cell Lymphoma of the inguinal nodes was originally diagnosed in 2006 s/p chemotherapy and hormone therapy with remission. Now the patient presents at your facility with palpable lymphadenopathy in the right axillary region. An excision...

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding On the evening following total hip replacement surgery, the patient is found to be confused and disoriented. The progress notes indicate the patient’s mental status changes are secondary to pain medication, which will be reduced. The PCA pump is removed resulting in the patient’s mental status returning to...

Building a Cancer Program is like building a tree house. Elizabeth R. Patena, M.D., CTR Vice President of Cancer Registry Choose the tree where you want to build a tree house. In your case, you have already selected the tree which is your facility. Begin with a platform. The platform is the key element of any tree house which will provide a secure foundation for the...

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding A discharge summary reveals the patient’s principal diagnosis to be acute cerebrovascular accident with right sided upper and lower extremity weakness. This diagnostic statement presents two options for the coder: code the symptom as documented or discuss the record with the CDS to determine if a query is...

Situation: Cathie Wilde, RHIA, CCS, Vice President of Coding Services Sixteen year old male was driving a dirt bike in the woods when he was thrown from the vehicle resulting in an ankle fracture. What would the external cause E code be for the above situation? E821.0? E821.2? Here are my thoughts… Review of the definitions preceding the transport accident E codes...

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding An elderly patient presents with altered mental status and fever. The patient is found to be hypotensive, with a respiratory rate of 22, WBC’s > 12,000 and elevated lactic acid. The documented impression in the history and physical and throughout the progress notes is sepsis like features. For another...

Case Scenario: A 90 year old patient is admitted to the hospital with community acquired pneumonia. During the course of hospitalization, the patient develops some aphasia and a stroke is suspected. A CT scan is inconclusive and a MRI is unable to be done as the patient has a pacemaker. The physician signs out the final diagnoses as: community acquired pneumonia, TIA vs....

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding Take a moment to think about the physician queries you initiated or thought about initiating this week, specifically, those for abnormal lab results without a documented corresponding diagnosis. An example is a patient that underwent a colectomy; their pre-op HCT was 40 which decreased to 30 postoperatively....

Scenario: Cathie Wilde, RHIA, CCS, Vice President of Coding Services A patient was seen in the ER previously for a foot laceration occurring after stepping on glass while barefoot. The wound was sutured at the time. He now is admitted to the hospital three days later for treatment of foot cellulitis. Question: What is the Principal Diagnosis – complicated open wound...

Lynn Salois, RHIT, CCS, CDIP, Director of Coding Coding a medical record with incomplete documentation jeopardizes coding accuracy and negatively impacts reimbursement. However, sometimes real world situations prohibit Coding Managers from adhering to best practice standards. In the following scenario the discharge summary provided clarifying documentation; leading...

Cathie Wilde, RHIA, CCS, Vice President of Coding Services A forty-six year old patient arrives in the emergency room with chief complaint of confusion as described by patient’s spouse. A thorough work up is undertaken including blood work, radiological testing and a neurology consult. No etiology for the confusion is identified. The attending physician documents the...

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding Clinical Documentation Improvement Managers (CDIMs) continually monitor the success of their healthcare organization’s CDI program. The metrics they use commonly include volume of queries issued, query success, case mix data, severity of illness, and risk of mortality data. However, there is another critical...

Cathie Wilde, RHIA, CCS, Vice President of Coding Services It is important that your coding staff identify and code all pertinent secondary diagnoses that meet additional diagnoses criteria (as outlined by Coding Clinic, 4Q 2008, p. 305-306). In this month’s case, the identification of another secondary diagnosis meant an extra $22,000 in hospital revenue.More than...

Cathie Wilde, RHIA, CCS, Vice President of Coding Services Do the diagnosis codes that you submit on your claims support medical necessity? When you are coding patient encounters, do you assign diagnosis code(s) based only the final diagnosis documented by the provider, or do you review the record for chronic conditions that are being followed and should also be...

Strong communication between clinical documentation specialists (CDS) and clinical coders is vital to the success of any clinical documentation improvement program. But additional benefits may be gained through ongoing exchange between these two teams. Here’s a real-world example. Situation: In reviewing the medical record, the coder notes disconnect between the physician...

Cathie Wilde, RHIA, CCS, Vice President of Coding Services A sixty-two year old patient is seen in the emergency room complaining of rectal bleeding. His HCT is 24 and his platelet count is 38,000. The admitting diagnosis is GI bleed. Makes sense. However, per the history and physical, the patient has a history of a bleeding arteriovenous malformation and...

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding In reviewing the medical record the coder notes disconnect between the physician documentation and the CDS documentation. Initial physician documentation indicates pneumonia with later documentation indicating acute bronchitis. The CDS worksheet indicates acute bronchitis. Was the pneumonia ruled out? Did...

Luisa Dileso, RHIA, MS, CCS, Director of Coding Education Clinical coders are often sequestered within health information management (HIM) and incented to only code…not expand their horizons by keeping abreast of nationwide healthcare initiatives. But is this the best management approach? Situation: Several coders were breaking for lunch and an important conversation...

Nancy Hinchliffe, RHIA, CTR, Vice President of Cancer Registry By Nancy Hinchliffe, RHIA, CTR, Vice President of Cancer Registry, MRA According to the Centers for Disease Control and Prevention (CDC), more than 16 million Americans were diagnosed with cancer between 1990 and 2004. Not only are new cancer cases being identified daily, but patients are surviving longer...

Lynn Salois, RHIT, CCS, CDIP, Director of Coding An elderly patient with a past medical history of CHF presents to the hospital with dyspnea and hyponatremia. Review of the history and physical indicates the patient’s daily Lasix dose was increased recently. What to do? Dig deeper! Upon further review, progress notes revealed that the patient has been non-compliant...

Luisa Dileso, RHIA, MS, CCS, Director of Coding Education Recently, an inpatient coding validation audit was scheduled to be performed for a MRA client hospital. However clinical program passwords and system access had not been set up or tested. We simply could not get access to the medical record information we needed to conduct the work. Consequently, the review...

Cathie Wilde, RHIA, CCS, Vice President of Coding Services An 88 year old patient was admitted to the hospital after suffering a cerebral infarct. After review of the record, code 434.91 was assigned as the Principal Diagnosis along with several other chronic condition codes resulting in a DRG of 066 – Intracranial Hemorrhage or Cerebral Infarction without CC/MCC. No...

Luisa Dileso, RHIA, MS, CCS, Director of Coding Education So the big question is, “How do I mitigate that drop in productivity?” You could hire an outsourcing company to provide coders through the transition. If you choose this option, go ahead and secure your contract now. Coding companies also expect an increase in work, and therefore demand, over the next two...

So the big question is, “How do I mitigate that drop in productivity?” One answer is to hire more coders. However, you can’t find them now – never mind when the demand spikes for I-10. Here is tip #2 of five in our series to improve coder productivity and accuracy. You’ll see immediate results while also preparing for your long-term needs! Tip #2: Make the Most of Your...

Luisa Dileso, RHIA, MS, CCS, Director of Coding Education ICD-10 is around the corner and many sources are predicting an initial drop in coder productivity of up to 50 percent. This will be followed by an ongoing drop in productivity of 10-20 percent. In fact, a former HIM Director from Canada said her coders were never as productive in ICD-10 as they were in ICD-9....

Luisa Dileso, RHIA, MS, CCS, Director of Coding Education Not the most exciting project and perhaps the most underestimated is the redesign of forms to accommodate the transition to ICD-10. Those of particular concern are those critical for clinical documentation by doctors, nurses, ancillary departments and others. Beware, this will take much longer and cost much...