MRA Thought of the Day – Cardiac Arrest (427.5) as the Principal Diagnosis?

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

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....

MRA Thought of the Day – What Else is New in 2013?

Charlie Saponaro - CEO Cancer Registry Leave a Comment

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...

MRA Thought of the Day – Understanding the 2-Midnight Rule Documentation Requirements

Charlie Saponaro - CEO Medical Coding Leave a Comment

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...

MRA Thought of the Day – New FY 2014 “2-MIDNIGHT” RULE – A Documentation Concern

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

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...

MRA Thought of the Day – The Stakes Are High for a Successful CDIP

Charlie Saponaro - CEO CDI Leave a Comment

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...

MRA Thought of the Day – When to Charge an Initial Neonatal Critical Care CPT?

Charlie Saponaro - CEO Medical Coding Leave a Comment

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...

MRA Thought of the Day – What’s New in 2013?

Charlie Saponaro - CEO Cancer Registry Leave a Comment

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 ...

Preterm Labor = Preterm Labor…Or Does It?

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

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....

MRA Thought of the Day – Copy and Paste Practices: Will Your Services Remain Billable?

Charlie Saponaro - CEO Medical Coding Leave a Comment

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...

MRA Thought of the Day – One Time Diagnostic Statement

Charlie Saponaro - CEO Medical Coding Leave a Comment

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...

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