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

Charlie Saponaro - CEO Medical Coding Leave a Comment

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?

MRA Thought of the Day – Cytology as Diagnostic Confirmation

Charlie Saponaro - CEO Cancer Registry Leave a Comment

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...

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

Charlie Saponaro - CEO Medical Coding Leave a Comment

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...

Incidental vs. Complicating?

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

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...

MRA Thought of the Day – Lymphoid Neoplasm and MPH

Charlie Saponaro - CEO Cancer Registry Leave a Comment

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...

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

Charlie Saponaro - CEO Medical Coding Leave a Comment

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...

MRA Thought of the Day – Building A Cancer Program Is Like Building A Tree House

Charlie Saponaro - CEO Cancer Registry Leave a Comment

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...

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

Charlie Saponaro - CEO Medical Coding Leave a Comment

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...

MRA Thought of the Day – E Code Definitions

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

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...

MRA Thought of the Day – Don’t Be Fooled By Sepsis-Like Features

Charlie Saponaro - CEO Medical Coding Leave a Comment

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...

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