MRA Thought of the Day – Pattern of Use: Watch Your Fifth Digits

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

Scenario: 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 twenty-five years drinking at least one six pack of beer …

MRA Thought of the Day – Avoid an ICD-10 Transition Roadblock: Assess Clinical Documentation Now

Charlie Saponaro - CEO Coding Leave a Comment

Situation: 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? Response: True -Coding professionals will be ready for the ICD-10 transition on October …

MRA Thought of the Day – Cytology as Diagnostic Confirmation

Charlie Saponaro - CEO Cancer Registry Leave a Comment

Situation: 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 smears. It can also be paraffin block specimens from concentrated spinal, pleural, or peritoneal fluid. Does cytology confirmation alone constitute a …

MRA Thought of the Day – Avoid Revenue Loss with Critical Care Services

Charlie Saponaro - CEO Coding Leave a Comment

Situation: 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 their documentation while trying to adhere to a busy and complex …

Incidental vs. Complicating?

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

Situation: 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 patient plans to terminate the pregnancy at Planned Parenthood following discharge and does …

MRA Thought of the Day – Lymphoid Neoplasm and MPH

Charlie Saponaro - CEO Cancer Registry Leave a Comment

Situation: 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 biopsy of the right axillary mass reveals B-cell lymphoma with features intermediate between DLBCL …

MRA Thought of the Day – Documenting Acuity Clears Up the Confusion

Charlie Saponaro - CEO Coding Leave a Comment

Situation: 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 baseline. Do any of the diagnostic statements require further specification for …

MRA Thought of the Day – Right Sided Weakness: Coder and CDS Collaboration Creates a Win-Win Situation

Charlie Saponaro - CEO Coding Leave a Comment

Situation: 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 warranted for clarification of the weakness. The coder recognizes right sided …

MRA Thought of the Day – E Code Definitions

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

Situation: 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 located in the ICD-9-CM book provides some …