Spinal fusions can be performed using a variety of techniques, and selection of the correct sixth character is crucial in identifying the device/material used to perform the fusion. Understanding the different methods of spinal fusions and associated devices, along with Official Coding Guidelines and Coding Clinic, can help to alleviate spinal fusion confusion.   ...

According to various sources on the Internet, the first example of recorded history began 5000 years ago – in approximately 2600 BC. An ailment thought to be diabetes mellitus (DM) was recorded by Egyptians around 1550 BC. It’s easy to see that diabetes has been around for a long, long time. Even ancient Indians were aware of the condition, as they identified diabetes...

Read the first part of this blog, "Coverage for Medicare Colonoscopies" here.  Average Risk Colonoscopy  Average risk colonoscopy is defined as a test ordered in the absence of signs or symptoms or other evidence of illness, the physician interpreting the diagnostic test should report the reason of the test as the primary ICD-10 CM code.  The results of the test, if any,...

With several major events including the pandemic and its domino effects (e.g., social isolation, job loss), racial strife, natural disasters, and senseless shootings the past eighteen months or so has taken its toll on humankind in the form of increased mental health distress and drug abuse. The increase in mental health challenges patients are facing provides a good...

Megaloblastic anemia is a form of anemia that occurs when the body’s bone marrow produces structurally abnormal and unusually large, immature red blood cells known as megaloblasts. A deficiency in healthy, mature red blood cells can result in fatigue, pallor, lightheadedness, aches and pains, muscle weakness, and dyspnea. Other symptoms can include gastrointestinal...

About 10% of neonates require some form of respiratory assistance at birth. To assign ICD-10-PCS ventilation codes correctly, it is important for Coding Professionals to understand the difference between invasive and noninvasive ventilation. An understanding of respiratory assistance given solely for the purposes of newborn resuscitation vs ongoing respiratory assistance...

My first blog on Diabetes Mellitus (DM) covered the pathophysiology of DM Types 1, 1.5, and 2. Read Part 1 Here. Types 1 and 2 (and even 1.5, though not “officially” recognized) are considered primary types of DM. There are other forms of DM that are due to underlying conditions or are “induced” by drugs or chemicals. Complications of primary DM include: hyperglycemia,...

Colonoscopies are critical to our well being. How these important services are documented and coded is equally as important. Medicare covers screening colonoscopies every 24 months if the patient is at high risk for colon cancer or once every 120 months, or 48 months after a previous flexible sigmoidoscopy. No cost to the beneficiary for screening colonoscopies and the...

In my estimation, we in healthcare, love initials after our last names. While I have no actual data to support my “theory”, I’d say that most of us involved in healthcare (whether practitioners or allied health professionals) have more that one credential. Professional credentials are our way of proving our expertise in a given subject such as HIM, coding, compliance,...

As value-based healthcare models continue to grow, the collection and documentation of social determinants of health data has become a key factor in improving patient care and outcomes. As HIM and Coding Professionals, our role in understanding, collecting and appropriately reporting social determinants of health is more important than ever. What are social determinants...