Back To Basics – Section III. Reporting Additional Diagnoses

Cathie Wilde Articles, Blog, Coding Leave a Comment

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 evaluation; or therapeutic treatment; or diagnostic procedures; or …

E/M Leveling: Compliance, Correct Coding and Best Practices

C. Matheson Coding Leave a Comment

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 level of care provided seems to …

Understanding the Difference: Swan-Ganz Catheterization vs. Right Heart Catheterization

Cathie Wilde Coding, Outsourcing, Uncategorized 1 Comment

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 …

The Future of Health Information Management

Karen G HIM 2 Comments

As I reflect on all the changes in the field of health Information, we continue to face exciting times and the ability to reinvent ourselves. Why is that exciting? Because we can create something that doesn’t exist. We need to lead the way for our teams of the future in order to encourage our professionals to increase their knowledge by …

HIPAA Authorization versus Patient Directive

Susan Hagan HIPAA Authorization 1 Comment

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 instructing HHS to clarify …

Don’t be in Denial about Denials

C. Matheson Coding Leave a Comment

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 inundated with payer …

Matters of the Heart: FY2018 Code Changes Impacting Heart Failure

C. Matheson CDI, Coding 2 Comments

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 …

What’s the Skinny on Obesity and BMI Coding??

C. Matheson CDI, Coding 1 Comment

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 …

What do all those radiation treatment modality codes mean?

Kerri Helms Cancer Registry, Coding Leave a Comment

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 assigned to evaluate …