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

C. Matheson, RHIA, CCS Medical Coding 1 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...

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

Cathie Wilde, RHIA, CCS - Director, Coding Services Outsourcing Leave a 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 internal...

HIPAA Authorization versus Patient Directive

Charlie Saponaro - CEO Leave a 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...

Don't be in Denial about Denials

C. Matheson, RHIA, CCS Medical 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...

Matters of the Heart: FY2018 Code Changes Impacting Heart Failure

C. Matheson, RHIA, CCS CDI Leave a Comment

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 each year. ...

Rocky Roads: Patient Right of Access & Patient Centered ROI

Charlie Saponaro - CEO CDI Leave a Comment

With the OCR issued FAQs on patient HIPAA rights to access PHI being out now for over a year, I know many of you are feeling more confident than ever on how to handle these pesky third party requestors who demand records under the HITECH Act. Or perhaps you are just as challenged as the rest of us? The FAQs clarified that individuals (patients according to HIPAA...

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

C. Matheson, RHIA, CCS CDI 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?

C. Matheson, RHIA, CCS Cancer Registry 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...

Documentation Management in Support of the Electronic Health Record

C. Matheson, RHIA, CCS Outsourcing Leave a 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...

ROOT OPERATION DILEMMA: CONTROL vs. DESTRUCTION

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

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 angioectasia...

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