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

C. Matheson CDI, Coding Leave a 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?

MRA 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 …

Documentation Management in Support of the Electronic Health Record

MRA Coding, Leadership, Outsourcing 1 Comment

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 include that information when releasing protected health …

ROOT OPERATION DILEMMA: CONTROL vs. DESTRUCTION

Cathie Wilde, RHIA, CCS, AHIMA Approved ICD-10-CM/PCS Trainer CDI, Coding 3 Comments

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 …

2017 HIM Challenges in Data Integrity, Revenue Integrity & Denial Prevention

MRA CDI, Coding, Disclosure Management Leave a Comment

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 technology and resources to conduct audits, analyze findings and implement …

Insight into Coding Diabetic Eye Conditions

C. Matheson CDI, Coding, Leadership, Outsourcing Leave a Comment

  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 …

Bringing Awareness to Kidney Cancer

MRA Cancer Registry, Coding, Outsourcing Leave a Comment

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 …

The Evolving Landscape for Health Information Management

MRA CDI, Coding, Leadership, Outsourcing Leave a Comment

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 professionals need to manage business, clinical and information systems.  Some of the challenges …

The Principal Diagnosis Effect

Cathie Wilde, RHIA, CCS, AHIMA Approved ICD-10-CM/PCS Trainer Coding, Outsourcing 2 Comments

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 figuring the abscess will not make …

ICD-10-PCS Coding For Venous Access Lines and Catheters

C. Matheson Coding, Outsourcing 7 Comments

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, or femoral vein. …