Social Determinants of Health: A Coding Guide

Caitlin Wham, CCS Health and Wellness Leave a Comment

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...

Helpful Snippets from a Coding Director

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

As coders, we often encounter common coding scenarios that seem straightforward, but we may need to be reminded of applicable guidelines and coding advice. Sometimes this requires us to seek further clarification if the documentation is not clear. With awareness of the documented circumstances and pertinent guidance, the potential implications for inaccurate coding can be...

Tips for Wound Care Documentation

Erika Stevens, CPC - Senior Professional Physician Coding Specialist Outpatient Coding 1 Comment

Active wound care procedures are performed to remove devitalized and/or necrotic tissue to promote healing. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. These services are billed when an extensive cleaning of a wound is needed prior to...

DIABETES MELLITUS: The Pathophysiology of DM

Becky Buegel, RHIA, CDIP, CHP Medical Coding Leave a Comment

There’s an old saying about “writing what you know.” Keeping that in mind, I’ve decided to write a series of blogs about diabetes mellitus (DM) since I have Type 2 DM. Actually, I suspect I really have Type 1.5, AKA LADA. You may not even know the terms Type 1.5 or LADA, as presently, there is no official recognition or code number for Type 1.5. However, before we can...

ICD-10-CM and ICD-10-PCS Coding for Vaginal Deliveries

C. Matheson, RHIA, CCS Medical Coding 1 Comment

Vaginal deliveries are the most common type of obstetric delivery, but there can be great variety among the diagnoses and procedures involved with these deliveries. Being familiar with pertinent ICD-10-CM and ICD-10-PCS coding guidelines and knowing a little about what the ICD-10-PCS character values for these codes represent will go a long way in helping you make...

Back to the Basics: How to Do an Internal Coding Audit

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

Internal coding audits are an important tool in any hospital’s compliance program. They illuminate potential areas for corrections prior to scrutiny by payers and regulators, which can help reduce payer denials and protect revenue. Additionally, performing regular, ongoing internal auditing can improve clinical documentation and coding initiatives, enhance data integrity,...

Coding in the Time of Covid: CMS releases 12 New ICD-10-PCS

C. Matheson, RHIA, CCS Covid-19 Leave a Comment

During this time of year in the coding world we are preparing for the October 1st ICD-10-CM and PCS coding updates, but we were recently surprised with an announcement on July 30th from The Centers for Medicare and Medicaid (CMS). Twelve new ICD-10-PCS procedure codes concerning Covid-19 therapeutics became effective August 1, 2020.  Per the CMS website announcement on...

NEW E/M OFFICE VISIT GUIDELINES PART III

Erika Stevens, CPC - Senior Professional Physician Coding Specialist Best Practices Leave a Comment

E/M office and other and other outpatient visit guidelines will be changing as of January 1, 2021. Below are further details regarding these changes: Read Part I and Part II of this blog for more information. Major E/M revisions for 2021 regarding time of patient encounters include Extensive E/M guidelines additions, revisions, and restructuring Deletion of code 99201...

Preventing Medical Coding Errors

Charlie Saponaro - CEO Medical Coding Leave a Comment

Conducting regular audits of your coding and billing procedures is a great way to identify and eliminate upcoding and incorrect coding incidences within your practice. In a recent article from Becker’s , it is estimated that hospitals overbilled Medicare by $1 billion from inaccurate coding. The office of Health and Human Services (HHS) Office of Inspector General cited...

Don’t Overlook Specialty Areas When Performing Fixed vs Variable Cost Analysis

Charlie Saponaro - CEO Medical Coding Leave a Comment

When you are considering the pros and cons of a variable vs fixed cost structure, don’t overlook certain specialty areas such as registries. For example, On April 2, 2020, the American College of Surgeons (ACoS) sent out a newsletter stating that ACS Accreditation and Verification Programs have been granted an extension of one year for hospitals currently accredited and...

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