Each year the AMA (American Medical Association) publishes new, revised, and deleted codes to the CTP code set, including logic and rationale related to the updates. In this blog, we will discuss the 2022 CPT changes regarding hypospadias repair and ultrasound-guided focal ablation of the prostate. Hypospadias Repair For FY 2022, there were several editorial revisions to...

The prevalence of pressure injury and/or pressure ulcers has continued across healthcare, with some estimates and studies saying that in the last 10 years they have increased by 63%. The proper ICD-10-CM coding of these takes clinical knowledge, comprehension and proficiency of documentation and the coding conventions and guidelines.  Deep tissue-pressure injury or DTPI,...

Monkeypox is a rare virus that has been increasing in frequency over the past 3-4 months here in the United States. Vaccinating against Monkeypox is a recommended medical practice. Having the associated laboratory test code and vaccine product code(s) to capture this service and data is important to have in place for use across healthcare settings. Monkeypox is a rare...

What do hypertropia, crossed eyes, and strabismus have in common? They’re different names for the same condition – misalignment of the eyes. Using the nose as the “common landmark” as it were, the condition that causes an eye to deviate away from the nose, while the other remains focused is a form of strabismus diagnosed as exotropia. The condition that causes an eye to...

Each year the AMA (American Medical Association) publishes new, revised, and deleted codes to the CTP code set, including logic and rationale related to the updates. The CPT code set for 2022 includes several changes to the urinary system as well as a new Category III code. In this blog, we will discuss the changes regarding periurethral balloon continence device...

As every coder knows, the hip, one of the largest joints in the body, is a ball and socket joint. Looking at the hip’s anatomy, the “socket” portion is formed by the acetabulum, and the “ball” is the upper end of the femur. The bony surfaces of the hip are covered by articular cartilage that cushions the bones, permitting easy movement. The synovial membrane surrounding...

Each year the AMA (American Medical Association) publishes new, revised, and deleted codes to the CPT code set, including logic and rationale related to the updates. The CPT code set for 2022 includes several changes regarding osseointegrated auditory implants. These changes include revisions of guidelines and parenthetical notes, as well as new, revised and deleted...

The Centers for Medicare and Medicaid Services (CMS) released their proposed Fiscal Year 2023 ICD-10-CM coding update and the final ICD-10-PCS codes changes. The ICD-10-CM proposal has some significant changes and new codes. The ICD-10-CM does have a high volume of new code to absorb and learn about. The ICD-10-PCS is always of interest with new procedure and devices...

Recent media reports document an increase in suspected and confirmed cases of the monkeypox virus. Monkeypox, first detected in lab monkeys in 1958, may have earned its moniker from the lab monkeys, but it’s actually thought it originally spread to humans from wild animals like rodents; today’s thinking is that it’s either spread by wild animals or from contact with other...

Each year the AMA (American Medical Association) publishes new, revised, and deleted codes to the CTP code set, including logic and rationale related to the updates. The CPT code set for 2022 includes several changes regarding spinal fusions- including revisions of guidelines, parenthetical notes, definitions and coding instructions. The key changes regarding spinal...

The clinical coding of “Underdosing” has some very specific guidelines which must be understood and followed. We see “underdosing” scenario’s occur in both outpatient and inpatient encounters. Several ICD-10-CM codes will need to be assigned in order to capture the underdosing patient encounter accurately.  The clinical coding of a condition or diagnosis of “Underdosing”...

The question is simple – What is anemia? However, the answer is not necessarily so simple. Anemia is a condition that is marked by a deficiency of red blood cells, or hemoglobin. Anemia can be linked to a variety of conditions and diseases, and can affect people of all ages, races, and ethnicities. The more common forms of anemia are noted below.  NUTRITIONAL-DEFICIENCY...

In March 2022, the U.S. Department of Health and Human Services released the updates for its Strategic Plan. All operating and staff divisions within the HHS and input from Congress, Tribes, Tribal, and Urban Indian Organizations, the Office of Management and Budget, and the public sector contributed to its development. For FY 2022 – 2026, HHS addresses and tracks five...

The Office of Inspector General (OIG) released in mid-March 2022 their annual report and statistics for 53 Medicare Fraud Control Units across the country. Significant investigative work and recoveries were obtained in 2021 totaling $1.7 billion recovered and 1,105 convictions. The 2021 annual Office of Inspector General (OIG) Medicaid Fraud Control Units (MFCUs) report...

Your next chart has the diagnosis “scleroderma.” Being familiar with medical terminology, you know “sclero” means “hard”. Derma, of course, means skin, so the diagnosis means hard/hardened skin. If you’re using coding books instead of an encoder, you’re probably thinking skin codes fall under Chapter 12 – Diseases of the Skin and Subcutaneous Tissue as you flip through...

The CPT code set for 2022 includes 249 new codes, 93 revisions, and 63 deleted codes that went into effect January 1st, 2022. Changes in codes and guidelines were made in all sections of CPT- so be sure to review the 2022 CPT code set in its entirety to ensure proper coding and reporting. Key changes in the Surgery section will be highlighted in this blog. Integumentary...

In 2021, CMS released the Official ICD-10-PCS Coding Guidelines for fiscal year 2022, which went into effect October 1st. The FY 2022 PCS guidelines include three guideline revisions in the Medical and Surgical section (B3.7, B4.1c, B4.8) and two guideline revisions from the New Technology section (E1.a, E1.b). Although key changes will be highlighted in this blog, be...

Over the past 20 years, Healthcare has seen an increased interest in the impact and influence of “Social Determinants of Health” or SDOH. Recent the Centers for Medicare and Medicaid Services (CMS). Health plans themselves have become more interested in SDOH and the associated cost of care present and future. Now we have CMS Medicare Part C raised attention to SDOH also. 

The CPT coding system was introduced in 1966, and was originally intended to simplify documenting procedures that physicians performed. By 1970, the system had changed to include lab procedures, and the codes had expanded to five digits. The concept of modifiers was introduced in the third edition of CPT in 1973. Modifiers provide additional information about a procedure...

The Office of Inspector General released in January 2022 an audit report on Medical Advantage for Healthfirst Health Plan, Inc. The identified errors were related to some specific diagnosis codes and Hierarchical Condition Categories (HCCs). Another Medicare Advantage Audit Report from the OIG! This particular audit report by the Health and Human Services (HHS) Office of...

Just about anyone who’s taken medical terminology recognizes the term “eponym”. The Merriam Webster dictionary, along with the Wikipedia website have the same definition for the word “eponym”. Roughly paraphrased, an eponym puts the name on a place, thing, discovery, or invention of the person who is believed/thought to have “discovered” it. Being awarded an eponym in...

In 2021, CMS released the fiscal year 2022 code descriptions, tables, index and addendum which went into effect October 1st. The updates included 32 deleted codes, 20 revised codes, and 159 new codes. Although key changes will be highlighted in this article, be sure to review both the guidelines and code updates in their entirety to ensure proper coding and reporting. ...

Joining the ranks of physician and nursing shortages is a medical coder shortage of unprecedented heights. Hospitals need to quickly alleviate this problem or risk losing thousands of dollars in unbilled charges. Here’s a look at four actionable solutions to the coder shortage gap in hospitals. First, why is there a coder shortage? Sickness running rampant throughout an...

Introduction Heart disease, which includes coronary artery disease (CAD), is the leading cause of mortality in the U.S. To reduce the incidence of mortality, approximately 1.2 – 2 million cardiac stents are implanted each year worldwide. A cardiac stent or stents are deployed (inserted) into one or more affected cardiac arteries most commonly via a minimally invasive...

When the final rule for the FY2022 Inpatient Prospective Payment System (IPPS) came out, it included the statement that we will now have clinical coding updates twice a year for ICD-10-CM and ICD-10-PCS, once in April and the usual large update in October. Keeping with their statement, the Centers for Medicare and Medicaid Services (CMS) announced that three (3) new...

The Improper Payment Measurement or IPM provides statistical data on parts of the Medicare programs and reports overpayments and underpayments. The Medicare Part C beneficiary-level of payment errors from a given year is included and certainly is something to keep an eye on. The CMS IPM sample taken is extrapolated to determine the payment error to the risk adjustment...

CAM? Isn’t she some female American country music singer/songwriter? No – a CAM is a rotating or sliding piece in a mechanical linkage that has something to do with turning rotary motion into linear motion – at least that’s what the dictionary said. Besides, what would have female country music singer or a car engine part have to do with acupuncture? Well, they have...

According to a Pew Research Center analysis, retirement looms for 3.5 million retirees over the next year, including the most recent labor force data.1 Many organizations face this worrisome predicament, yet many health information management departments struggle with being proactive in their planning efforts. This week's blog post asked three healthcare industry leaders...

Several important updates and additions were made to the ICD-10-CM Official Guidelines for Coding and Reporting for fiscal year 2022. Although key changes will be highlighted in this article, be sure to review the new and revised guidance in its entirety to ensure proper diagnosis coding and reporting. Additionally, visit our blogs about 9 Tips to Calm Coder Anxiety, ...

The American Medical Association (AMA) announced the addition to the Current Procedural terminology (CPT® ) code set of a new COVID-19 booster for the Janssen Pharmaceutical Companies of Johnson & Johnson vaccine. The October 27, 2021, AMA press release explains that this vaccine is added to the other booster vaccine doses from both Pfizer and Moderna. The new CPT code...

Diabetes mellitus (DM) Types 1 and 2 are both known to be associated with a variety of complications. Some complications, like kidney disease or ophthalmic problems are, more often than not, related to poorly controlled diabetes. Acute metabolic complications are one of the many different types of complications that can develop in patients with diabetes. These...

There are many hints within the tabular index of the new ICD-10-CM codes for FY2022 that may help identify documentation query opportunities. Take a close look at these new codes, see those instructional notes; “Code first,” “Use additional code”, “Code also”, these are some the documentation hints. In addition, some of the new codes have a description or title that...

Mental, behavioral and neurodevelopment disorders located in Chapter 5 of the ICD-10-CM Coding Manual were first addressed in the August 10, 2021, MRA Blog (https://www.mrahis.com/blog/chapter-5-coding). Here, we will be specifically discussing the mental and behavioral disorders related to psychoactive substance use which are included in Chapter 5.   Alcohol and...

Chapter 21 in ICD-10-CM contains our “Z” codes. Z codes (other reasons for healthcare encounters) may be assigned as appropriate to further explain the reasons for presenting for healthcare services, including transfers between healthcare facilities, or provide additional information relevant to a patient encounter. The ICD-10-CM Official Guidelines for Coding and...

The American Medical Association (AMA) has announced their 2022 Current Procedure Terminology (CPT ®) new codes and changes. For 2022, there are 405 editorial changes in the 2022 CPT code set, including 249 new codes, 63 deletions and 93 revisions. So, for the coding professional, there is a lot to understand and learn about these new codes and changes. According to the...

MTHFR. Sounds almost rude, doesn’t it? However, it is NOT something for which your mother would threaten to wash your mouth out with soap, I promise. MTHFR stands for methylenetetrahydrofolate reductase – so obviously, using the abbreviation is easier than saying that mouthful every time. What, exactly, IS MTHFR? It’s a genetic mutation affecting approximately 30% of the...

As coders we are often torn when it comes to coding a diagnosis when the provider’s documentation isn’t perfectly clear. It may sound elementary, but we must go back to the Official Coding Guidelines and stick to those to ensure we are reporting the correct diagnosis based on the documentation. Per the Official Coding Guidelines, Section IV.H, “Do not code diagnoses...

It’s September so that means it’s the beginning of Fall AND it’s Sepsis Awareness Month. Who would have thought we needed a month dedicated to this topic? But we do! Over the past 20 or so years the topic of Sepsis, Septicemia, Septic Shock and alike has flooded healthcare research, conferences, and medical literature. Certainly, for HIM Coding and Clinical Documentation...

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.   ...

We continue with our discussion of “Respiratory Failure, please refer to Part I for information on the clinical aspects and on the ICD-10-CM coding classification of this diagnosis. Often we think of “respiratory failure” as a condition occurring in the inpatient setting, but it can also occur in the Emergency Room, but usually results in an admission. Medicare-Severity...

You’ve heard of them . . . NCDs or National Coverage Determinations. What are they really? Who do they apply to? And how can I learn more? National Coverage Determinations are specific to the United States healthcare system, and they fall under the Health and Human Services Department (HHS). They are specific coverage determinations which apply to Medicare for items,...

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...

The Food and Drug Administration’s (FDA) took action in the month of August 2021 to authorize an additional dose of COVID-19 vaccine for immunocompromised individuals, referred to as a “COVID Booster”. Both Pfizer and Moderna have been approved for this the third COVID-19 vaccine. Administration of the COVID-19 booster will first be provided to those with...

The Medicare-Severity Diagnostic Related Groups (MS-DRGs) with ICD-10-PCS mechanical ventilation code(s) have been cited by the Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector (OIG) as problematic and a compliance risk. In a June 2021 CMS Medicare Learning Network (MLN) publication #17107 ”revised”, this included mechanical ventilation...

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) in early August 2021 published a report titled, ”Medicare Continues to Make Overpayments for Chronic Care Management Services, Costing the Program and Its Beneficiaries Millions of Dollars”. The OIG conducted this audit with the objective to determine whether payments made by the Centers...

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,...

Do you have trouble with IR coding? It can be difficult to determine code selection but understanding the rules can go a long way to understanding how CPT code assignment works. It’s all about the position of the catheter and the hierarchy of the codes. In a non-selective catheter placement, the catheter stays in the original vessel that was punctured or advances only to...

The Centers for Medicare and Medicaid Services (CMS) released on August 2nd, the Fiscal Year 2022 final rule for both Inpatient Prospective Payment System (IPPS) and the Long Term Care Hospital (LTCH) Prospective Payment System. After receiving more than 6500 comments to the proposed rule for IPPS and LTCH PPS, the results include a policy regarding healthcare equality...

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...

Hip and knee replacements have been around for several decades, in fact, the first recorded attempt for a total hip replacement dates all the way back to 1891 when they created a femoral head replacement out of ivory. Hip and knee replacement procedures and implants have evolved since then of course, and today the implants are made of metal, plastic, or ceramic material. ...

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...

Don’t you love summertime? School is out, we are taking vacations and trips, barbeques, sunny days, AND the new ICD-10-CM codes get released! Yes, it has occurred already (earlier than expected), the FY2022 ICD-10-CM codes have been released by the Centers for Medicare and Medicaid Services (CMS). For those of you keeping track of the dates of these releases, this FY2022...

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,...

In this article we will highlight some key elements for Critical Care coding since these codes are watched closely by insurance payors. What is the definition of Critical Care? Per American Medical Association (AMA) CPT Professional 2021 codebook, critical care is defined as “…the direct delivery by a physician(s) or other qualified healthcare professional of medical care...

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...

Recently I was talking with a colleague about the most common coding errors or variances we’ve been seeing lately when conducting inpatient coding audits. The selection of the “Principal Diagnosis” and a “Missed or Unsupported Secondary Diagnosis” certainly were at the top of the list. But there are some other areas that we as HIM Coding professionals should also be aware...

Lots of excitement over the release of the FY2022 ICD-10-PCS (Procedure Coding System) changes which came out on June 4th, 2021. In addition, there are a few changes to the PCS “Official Guidelines” (i.e., 3.7B Control), that every inpatient coding professional needs to be aware of and understand. For FY2022 there are 191 new codes, 62 revised titles, and 107 deleted...

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 than one credential. Professional credentials are our way of proving our expertise in a given subject such as HIM, coding, compliance, CDI...

One of the more challenging areas of medical coding, is the diagnosis of “Respiratory Failure”. Not only does it take having a solid clinical understanding but also a succinct knowledge of the Official Guidelines for Coding and Reporting as well as knowing when to query for documentation specificity. Obtaining coding compliance does center around continually learning and...

Throughout my career in Health Information Management, one of the particular areas of focus for both auditing and education has been the coding of an additional or secondary diagnosis. Whether inpatient (acute care) or outpatient coding, confusion and even errors occur in this area. The Official Guidelines for Coding and Reporting are at the center of understanding when,...

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...

We all are aware of the currently available COVID-19 vaccines from AstraZeneca, Janssen (Johnson & Johnson), Moderna and Pfizer and their unique CPT® codes. These medical codes allow for each vaccine and immunization administration to be clinically distinct, allows for better tracking, reporting and analysis (i.e., utilization data). The American Medical Association has...

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...

Certain elements of documentation must be present to code infusions, injections, and hydrations properly. An order by the physician, which must be dated, timed, and signed with the name of the drug, the dose and the route of administration should be on file for services performed. Infusion services require direct supervision by medical staff. The coder should next ask a...

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...

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...

Have you noticed that we are reading and hearing more and more about ICD-11? Looking back over the past few years we see that in June 2018 the World Health Organization (WHO) published (released) ICD-11 for review and the World Health Assembly formally adopted this version on May 25, 2019 to be effective beginning January 1, 2022. In fact, WHO has a home page dedicated to...

Current Procedure Terminology or CPT® is the registered trademark of the American Medical Association (AMA). The codes in CPT are 5-characters in length, with over 10,300 Category I, II and III codes, Category I covers the Evaluation and Management visits, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and the Medicine Section codes. It is within the Medicine...

The daily news surrounding COVID-19 includes information and facts from those individuals who were diagnosed with COVID-19 but they now are in the recovery stage and have “Post-COVID-19” signs and symptoms. A recent study in Nature Medicine (March 22, 2021), titled, “Post-Acute COVID-19 Syndrome”, states the following: Acute COVID-19 usually lasts until 4 weeks from the...

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...

A recent study was published in the Journal of the American Medical Association (JAMA) on March 22, 2021 titled, “Body Weight Changes During Pandemic-Related Shelter-in-Place in a Longitudinal Cohort Study”. This study takes a look at the impact of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or COVID-19 public health emergency (PHE) regarding “...

The first quarter of the American Hospital Association (AHA) Coding Clinic for 2021 has been released and contains the updated AHIMA/AHA FAQ on COVID-19 coding, as well as the January 1, 2021 update to the Official Guidelines for Coding and Reporting. In addition, this edition contains several ICD-10-CM coding questions and answers, and ICD-10-PCS scenarios to help with...

It is widely acknowledged that interventional radiology is one of the most complex medical coding specialties to master. There are many reasons why interventional radiology coding is so very challenging, but one of the main reasons is that many codes may be required to accurately capture all of the steps of a vascular procedure. To achieve success with interventional...

The Office of Inspector General (OIG) released a report on the concerns surrounding inpatient hospital stays with high levels of severity between 2014-2019. There was a reported 20 % increase found in the DRG (Diagnostic Related Group) severity levels, which are the most expensive and costly. The report was titled: “Trend Toward More Expensive Inpatient Hospital Stays in...

When coding Angiography procedures in ICD-10-PCS, a number of variables can make it challenging to get the coding right. For instance, knowing what value a particular type of contrast maps to is necessary to assign codes accurately. To help you make correct character selections when coding angiography the information that follows provides a high level review of each...

Remote Patient Monitoring or RPM is expanding and expanding quickly. This type of technology can assist with the remote assessment and monitoring of chronic conditions such as, Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, Diabetes, Obesity, Hypertension, etc. This monitoring process allows for clinicians to address changes and/or concerns in the patient’s...

An issue was identified with the payment and cost sharing calculations on code G2025. Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) Claims with HCPCS code G2025 have been mass adjusted to correct the payment problem. Medicare Administrative Contractors (MACs) are reprocessing Federally Qualified Health Center and Rural Health Clinic claims with...

Understanding the anatomy, physiology and disease process is a significant part of our daily work and competencies as Health Information Management (HIM) coding and Clinical Documentation Integrity (CDI) professionals. Thus, keeping on top of clinical information like that of Sepsis and COVID-19 is particularly important as it can certainly aid in determining when to...

February is National Cancer Prevention Month which promotes taking personal action to lower your risks for cancer. These include making healthy lifestyle choices for diet, exercise, avoiding tobacco products, protection against the sun as well as getting recommended cancer screenings and vaccinating against certain viruses that can cause cancer (e.g., human papillomavirus...

The American Health Information Management Association (AHIMA) and the American Hospital Association (AHA) have been publishing COVID-19 ICD-10-CM/PCS information and guidance since March 20th, 2020, last year. The most recent update occurred on March 1st, 2021 and is worth a detailed review. The COVID-19 coding FAQ (Frequently Asked Questions) covers both “CM”...

We are all hearing and seeing news and information daily about the efforts to vaccinate the United States population against COVID-19 and progress is being made. With this medical effort there is a wealth of published guidance and facts that have been developed by the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC),...

In a recent Journal of the American Medical Association (JAMA) a study on the highest reimbursed DRG (Diagnostic Related Group) trends from 2012 to 2016 was released. Medicare DRGs or Medicare Severity DRG (MS-DRGs) payment system includes the capture ICD-10-CM codes for complications and comorbidities which has a significant impact to disease severity, payment, and...

You’ve got an education budget for 2021 and an entire team of motivated and knowledge-thirsty coders to teach. The challenging part? Choosing the topics. You need to choose wisely. After all, you’re taking coders out of a production environment for hours or even days at a time. Ideally, the information they glean is timely, immediately actionable, and relevant to your...

Coding Injections and Infusions for Chemotherapy Coding injections and infusions of chemotherapy agents often seems a little daunting, but understanding a few foundational definitions and principles can make code selection much easier. Read on to review the basics of injection and infusion coding that apply when reporting the administration of chemotherapy. Injections ...

The Centers for Medicare and Medicaid Services (CMS) has several programs they sponsor and/or support that target “improper payments”. One of those programs is Comprehensive Error Rate Testing or CERT. The purpose of CERT is to measure the Medicare Fee-For-Service (FFS) improper payments, which include Medicare Part A, Part B and Durable Medical Equipment and Suppliers....

The American Medical Association (AMA) released on January 19th, 2021 new CPT codes for the COVID vaccine administration and the vaccine by Johnson and Johnson, which is still pending approval by the FDA.  This COVID-19 vaccine was under development by Janssen Pharmaceutica, a division of Johnson & Johnson. The new CPT codes are: 91303    Severe acute respiratory...

We have all been keeping up with COVID-19 and the code and guideline changes that have evolved since original coding advice came out in February of 2020. The advent of code U07.1 was a “game changer”. This code was created and made effective after April 1, 2020. The coding directive in this code states: Use additional code to identify pneumonia or other manifestations. ...

Coding Spinal Fusion: PCS vs. CPT When circumstances call for coding the same procedure in both CPT and ICD-10-PCS, a number of variables can make it challenging to get the coding right. For instance, the rules and guidelines that dictate whether an accessory procedure is integral to the primary procedure or separately reportable vary with the type of codes you are using.

OBSTETRICAL INPATIENT DIAGNOSIS CODING – A REFRESHER Obstetrics is to coding as cats are to animal lovers, you either love or dislike that subset of coding (or the animal kingdom) and there's no in-between. Sometimes a refresher of the highlights related to obstetrical coding can be beneficial for ensuring accurate coding for this type of record or even re-ignite an...

Finding a Career in Medical Coding Choosing Coding for a Career The demand for medical coders is growing. In fact, the Bureau of Labor Statistics expects this field to grow by 22% through 2026, and it's not a coincidence. Coding is a great career choice for anyone who wants to be in a non-patient facing position within the healthcare industry. It also offers the benefits...

When a provider addresses additional conditions at a general examination visit, usually referred to as a Well-Child or Adult Physical encounter, coders are often left to decide whether to assign a “with” or “without” abnormal findings code. So, how can we easily decide which code to assign? Per Coding Clinic First Quarter 2016 “For the purpose of assigning codes from this...

2021 CPT Code Updates It’s the most wonderful time of the year…annual CPT code updates! Who doesn’t love a good code update, right? Well, for 2021, AMA gives the people what they want with the release of 329 changes to CPT as outlined below and all changes going into effect January 1, 2021. · 206 new codes · 54 code deletions · 69 code revisions Keep reading to get a...

To Code or Not to Code? That is the Question. Diagnostic Angiography with Therapeutic Interventions Stacie L. Buck, RHIA, CCS-P, RCC, RCCIR, CIRCC: President & Senior Consultant, RadRx One of the most common inquiries I receive about interventional radiology procedures is how to determine when to code for angiograms performed during the same session as a therapeutic...

Coding for pneumonia continues to be problematic for most coders. There are many types of pneumonia and documentation is often insufficient for coding to the level of specificity available in our current ICD-10 structure. Some of the specific types of pneumonia codes available include aspiration, bacterial, lobar, pneumonia due to influenza, ventilator associated...

Coding COVID-19 Infection in Newborns With the 2021 updates to the ICD-10-CM code classification came 14 new chapter specific guidelines. All but one of these guidelines is related to the coding of COVID-19 infection. Needless to say, COVID-19 is a big deal, and getting the coding for this condition correct has implications for both payment considerations and statistical...

Read parts 1 and 2 of this blog for more information about ICD-10-CM and ICD-10-PCS updates. FY 2021 Coding Guideline Updates:  The past two weeks we have discussed the ICD-10-CM and ICD-10-PCS coding changes effective October 1st, 2020. This week we will be reviewing any corresponding FY 2021 Coding Guideline Updates that are new or revised because of the annual coding...

ICD-10-PCS FY 2021 Updates Read Part 1, ICS-10-CM Coding Updates Here. as well as Part 3, Coding Guideline Updates, Here  The ICD-10-PCS update for FY 2021 will go into effect on October 1, 2020 and will cover patient discharges occurring from October 1, 2020, through September 30, 2021. This year’s updates include the addition of 544 new codes. There are no deleted, nor...

Read parts 2 and 3 of this blog for more updates on ICD-10-PCS and Coding Guideline Updates. ICD-10-CM Coding Updates effective October 1, 2020 (FY 2021) It is that time of year when the ICD-10-CM and PCS changes are right around the corner. Set to take effect on October 1, 2020 there are numerous updates to Official Coding Guidelines, ICD-10-CM, and ICD-10-PCS. Medical...

When coding podiatry procedures one of the most valuable tools you have is an anatomy chart. Understanding exactly where the provider is, what bones, ligaments and tendons are involved, will help you select your CPT and diagnosis codes. At times finding CPT codes thru an encoder can be challenging. Don’t be afraid to crack open the ol’ CPT book and peruse the related...

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,...

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...

Outpatient Clinical Documentation Improvement/Integrity is gaining more and more attention. Having a successful program involves preparation, planning and executive. As we discussed in Part I (in the previous RMC newsletter) there are several key components to an OP CDI program. A best practice is to identify one setting that you wish to focus your CDI program on to...

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...

Coding for pneumonia continues to be problematic for most coders. There are many types of pneumonia and documentation is often insufficient for coding to the level of specificity available in our current ICD-10 structure. Some of the specific types of pneumonia codes available include Aspiration, bacterial, Lobar, pneumonia due to influenza, Ventilator Associated...

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...

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...

A compliance task that each facility should perform to support the Health Information Management (HIM) department is performing coding audits. Coding audits are performed to access the accuracy of the diagnosis and procedures codes assigned to each patient’s chart. The timing of these audits can be performed monthly, quarterly, bi-annually, annually, or as often as the...

With our E/M office or other outpatient visits guidelines changing on January 1, 2021, below are the details explaining the changes. Read part 1 of this article HERE.   Choosing the correct E/M level beginning January 1, 2021 is based on:  The level of medical decision making (MDM) as defined for each service; or  The total time for E/M services performed on the date of...

It has been almost 30 years since evaluation and management (E/M) office visit documentation and coding has been changed.  These changes take place beginning January 1st, 2021.  The revised guidelines will improve documentation redundancy and support medical necessity.  In the past, the code selection was based on 3 key elements (history, examination, and medical...

As we continue to feel the impact of COVID-19 in the United States and continue canceling meetings to avoid travel and risks of exposure, many families are also concerned about their loved ones currently going through cancer treatment.  And many others are currently being diagnosed with cancer during this worldwide pandemic.  The big question is how does this impact...

The current pandemic has prompted the World Health Organization (WHO) to take the unusual step of establishing a unique ICD-10 code for COVID-19 cases, U07.1 five months prior to the traditional U.S. implementation date for new codes. The use of the code became effective with April 1, 2020 discharges and was accompanied by updated coding guidance to the ICD-10-CM Official...

What Does CMS Say?  Congress passed wavier 1135 that states Medicare and other commercial carriers have temporarily expanded services for reimbursement on several telehealth services.  Click here for list of covered services during this Public Health Emergency (PHE) due to COVID-19.  For additional information on COVID-19, click here.  CMS is now releasing News Alerts...

Do you know the difference between a CVA and TIA? When coding cerebral vascular accidents (CVA) and transient ischemic attacks (TIA), it is important to know the difference between the 2 diagnoses as well as the different types of CVA. While both a CVA and TIA are caused by blockages to the arteries of the brain, a CVA is a more serious condition and can cause permanent...

Making changes on the fly is never easy in any industry, especially healthcare - figuring out what platform to use, training staff and patients on how to operate video conferences, but more importantly, will you get paid? With the Corona Pandemic turning our revenue cycle upside-down due to the cancelling of most elective procedures, it’s more important than ever that we...

In this environment it’s hard to know what tomorrow will bring. If you watch the news, all you’ll see is a lack of hospital beds and overwhelming patient volumes. Meanwhile, hospitals and clinics around the country are laying off staff because elective and non-emergent procedures have been cancelled to clear the decks for COVID patients. To add to the complexity, many...

Coding diagnoses from ICD-10-CM, Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders, does not prove to be an easy task. Psychiatry and mental health professionals use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) for applying diagnoses, which does not always correspond equally to codes from ICD-10-CM, and it is up to the...

There were 6 codes deleted for 2020 and 9 new codes were added under the Health Behavior Assessment and Intervention section. These family of codes were first established in 2002. With increased awareness and need for these types of services there was a need for more code revisions. Codes 96150-96155 have been deleted and replaced with the new codes 96156, 96158, 96159,...

There are many procedures that are done to the nose, including turbinate resection, repair of nasal vestibular stenosis, septoplasty, endoscopic sinus surgery to name a few. These can be tricky to code in CPT, and documentation of course is key. Turbinate hypertrophy can cause an altered sense of smell, dry mouth, nasal congestion, facial pain and snoring. This can be an...

By Marianne Loeffler, COC, CPC, CPC-I, CRCR, MRA Charge Audit Validator Infusions & Injections are confusing – even on a good day. Facilities often leave money on the table – and a lot of it – simply because knowledge and resources may be limited.  This article will briefly discuss the key elements to be aware of when reviewing documentation to accurately code injections...

  Transcatheter Aortic Valve Replacement (TAVR) is also known as Transcatheter Aortic Valve Implantation (TAVI). Medicare officially refers to this as TAVR/TAVI, but either single acronym is correct. TAVR is a transcatheter surgical procedure in which an aortic valve replacement is performed without removing the damaged native valve. In simple terms, it is similar to...

The FY 2020 IPPS final rule was released by the Centers for Medicare and Medicaid (CMS) on August 2, 2019.[1] Below are five highlights to be aware of regarding changes to ICD-10-CM, ICD-10-PCS, and corresponding official guidelines in FY 2020. ICD-10-CM[2] Effective October 1, 2019 there are 273 new ICD-10-CM codes, 21 deleted ICD-10-CM codes and 30 ICD-10-CM code...

MRA and YES HIM Consulting have partnered to delivery coding education to healthcare organizations across the United States. For over 30 years, MRA is known for delivering operational efficiency, service excellence to organizational integration to Revenue Cycle, HIM, Compliance and Cancer Registry areas in healthcare organizations. YES HIM Consulting is a premier Health...

Do you ever feel like by the time your organization and coders get used to one regulation, the rules change?  These frequent changes and the rapid pace of healthcare technology and trends make it critically important to ensure compliance and ongoing training and education is provided for coding professionals.  Judging from the sheer volume of codes can be...

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,...

Simply mentioning a coding audit sends a shiver up a coder’s spine. The thought of scrutinizing their coding quality, as they strive to balance quality and productivity, can bring dread to even the most seasoned coder. But conducting internal or external coding audits are an important part of ensuring quality and regulatory compliance for hospitals and health systems....

  As we discussed last week, over the past decade, there has been a tremendous amount of consolidation in healthcare. For hospital-owned physician practices specifically, we have seen the number  rise from 35,700 in July 2012 to 80,000 in January 2018. Over the same period, there was over a 70 percent increase in the number of physicians employed by hospitals or health...

  One of the key trends to emerge from last month’s JP Morgan Healthcare Conference was the shifting mindsets of hospitals. For the last decade, hospitals have had a defensive mindset; acquiring or merging with smaller hospitals and physician practices to outpace their competitors and grow top line revenue. But to receive the full payoff of this consolidation, hospitals...

In coding, like most every other area of life, there is not one solution for every organization’s potential problems. Coding is an ever-expanding area of focus for most every healthcare organization, and nearly every health system and the facility has or is making substantial investments in coding staffs and making these departments more robust. There are hurdles and...

Preparing For the Upcoming Cancer Registry Changes: Time Is Short, but Support is Available By Susan Mackenzie, MRA For those of us working in the cancer registry profession, you are likely very much aware of the significant changes upon us that will dramatically alter the way we work and how we collect required data for the registry. The upcoming changes are extensive,...

One of the more prominent guidelines found in the ICD-10-CM Official Guidelines for Coding and Reporting is Section III. Reporting Additional Diagnoses but it isn’t always applied appropriately. The guideline states: For reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:clinical...

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...

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...

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...

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. ...

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...

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...

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...

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...

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...

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...

  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...

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 and waste in the urine. However, did...

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...

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...

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,...

Medical Coding Outsourcing We live in a constantly expanding environment for outsourcing services, and the coding and health information industry is no stranger to outsourcing. Whether it is full department outsourcing, hand-picked silos of outsourcing for specific hard to fill or hard to train services or outsourcing to augment your current staff, utilizing contract...

Organizations did a fantastic job preparing for ICD-10. However, now that the dust has settled, we need to drill down into the data. Specifically, case mix index (CMI). With more than two months’ worth of ICD-10 data, it’s easier to make comparisons and draw logical conclusions. If coding and/or documentation problems exist, they’re likely starting to emerge through your...

The following Latin proverb seems to be particularly relevant in light of ICD-10: “Times change, and we change with them.” By now, ICD-10 has spurred many changes in technology, templates, coding, documentation, and more. However, to be truly successful, organizations must look beyond their HIM internal processes and ask this question: Must the organization’s relationship...

Unfortunately, the silos between coders and CDI professionals still exist in many hospitals. In some organizations, the walls may be slowly coming down, but in others, the silos stand tall. The irony is these two roles actually have more in common than they might realize. With communication and collaboration, coders and CDI specialists actually have the power to make a...

As the ICD-10-CM/PCS deadline approaches, it behooves HIM professionals to remind CDI specialists and physicians about important components of a thoroughly-documented operative note. Such a note supports accurate code assignment for reimbursement, and it also provides an accurate record for continuity of care as well as quality initiatives and legal and research purposes.

Combat ICD-10 Information Anxiety Anxiety is always tough to combat, and with the implementation of ICD-10 quickly approaching, coders’ anxiety levels may be at an all-time high. The entire journey has been a rollercoaster, making it difficult to manage emotions and prepare mentally for a go-live date that has essentially been a moving target. Although the House of...

Flu During Peak Season It’s that time of year again—flu season. According to data from the Centers for Disease Control and Prevention (CDC), 43 states are experiencing high or widespread flu activity mostly due to the spread of the H3N2 virus. For the week ending December 27, 2014, visits for influenza-like illness accounted for 5.9% of all clinic visits. During this same...

Although CDI programs have typically been implemented in the inpatient setting, many organizations are beginning to turn their attention toward outpatient documentation as well. That’s because many of the same documentation deficiencies occur in both settings. Poor outpatient documentation—particularly in the emergency department (ED) record—can also affect inpatient code...

In today’s electronic world, coders have a variety of technology tools to make their jobs easier. These applications boost coder productivity while also improving code quality and accuracy. With the inevitable implementation of ICD-10, the reliance on coding technology will become even more prevalent—and important. Here are key coding resources every coder should be...

Role changes are on the horizon for coding professionals. With the implementation of Computer Assisted Coding (CAC), ICD-10 and Hospital Value-based Purchasing (HVBP), clinical coding will take on different forms and new responsibilities. Traditional coding careers may transition to auditors, data analysts or even clinical documentation improvement / integrity specialists...

How to Successfully Navigate Appeals Even with the temporary suspension of RAC reviews, hospitals continue to deal with insurance denials from a multitude of third party payers. Cathie Wilde, CCS Vice President of Coding Responding to these coding denials is time consuming. HIM, revenue cycle and coding professionals are further frustrated when they believe their...

Nothing is more dangerous than an incorrect code. Whether in ICD-9, ICD-10 or CPT, your organization’s coding practices must be ethical, complete, accurate and compliant. So how are you measuring coding quality today? Which of the following best practices do you use? Lynn Salois, RHIT, CCS, CDIP Director of Coding Perform periodic internal coding quality audits. ...

ICD-10 Implementation Process Every lesson learned is a step forward. This past week’s decision by the Senate certainly provided a few new lessons for hospitals. First and foremost, we are reminded to “never say never”. And secondly, we can now take a breath and contemplate how to respond. Serious questions now emerge for everyone. The first of these being, when will the...

Cathie Wilde, RHIA, CCS, Director of Coding Services Myocardial Infarction Coding Aside from the obvious code changes, a coder needs to be aware of some fundamental differences in guidelines for the coding of myocardial infarctions. The ICD-9 fifth digit designation of unspecified, initial episode or subsequent episode of care is no longer applicable The time frame...

Cathie Wilde, RHIA, CCS, Director of Coding Services On January 31, 2014 CMS extended the “Probe & Educate” review process for implementation of the 2-midnight benchmark for an additional 6 months through September 30, 2014. What does this mean? The 2-midnight benchmark is still the rule for FY 2014 in determining the patient’s admission status. However, through...

Lynn Salois, RHIT, CCS, CDIP, Director of Coding A unique friendship between coder and radiologist is on the horizon. It is actually not so unique, but rather very logical. ICD-10-CM fracture coding requires anatomical specificity, simply stated, which bone is broken and what part of the bone is broken? For example, fracture of subtrochanteric neck of the right...

Cathie Wilde, RHIA, CCS, Vice President of Coding Services The Office of Inspector General (OIG) conducted a study to determine to what extent hospitals that received electronic health records (EHR) Medicare incentive payments through the American Recovery and Reinvestment Act of 2009 (ARRA) had implemented recommended fraud safeguards for EHR technology. Two areas...

Lynn Salois, RHIT, CCS, CDIP, Director of Coding Situation: Some to do list items appear more challenging than others, or so we think. For example, creating an environment of teamwork and collaboration amongst the Coding and CDS group may seem like a monumental task, but in reality, it can be very simple. Begin with fostering two basic core values: Communication and...

  Cathie Wilde, RHIA, CCS, Director of Coding Services   Anemia Sequencing Scenario: A 66 year-old patient was diagnosed with carcinoma of the upper third of the esophagus after an admission for workup due to severe fatigue and is undergoing outpatient radiation treatment prior to surgery. However, the patient is admitted today with shortness of breath episodes and was...

  Cathie Wilde, RHIA, CCS, Vice President of Coding Services   Sudden Cardiac Arrest Situation Situation: A 45 year old man is admitted to the ER in cardiac arrest, bradycardia and tinnitus. History indicates that he was having a minor procedure in the physician’s office when he developed cardiac arrest following injection of lidocaine in anticipation of the procedure....

  Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education   CMS has finalized a significant change to its inpatient admission guidelines as part of the 2014 IPPS Final Rule[1], released August 1, 2013. As presented in a recent MRA blog, the 2-Midnight Rule basics are: For an inpatient stay to be deemed medically necessary, the physician must expect...

Cathie Wilde, RHIA, CCS, Vice President of Coding Services Situation: In the CMS 2014 IPPS Final Rule[1] effective October 1, 2013, the criterion for inpatient admission has been redefined with the implementation of the “2-midnight” rule. This differs from the current 24 hour benchmark for determining inpatient vs. observation stays. With this policy change, CMS...

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding The multitude of changes in the healthcare industry are forcing hospitals to re-design and re-energize their Clinical Documentation Improvement Programs. To assist in this endeavor, HIM Directors and coding managers should examine the existing relationship between the two driving forces behind the success of...

Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education Scenario: The scenario is centered around a pediatric acute care setting and CPT codes 99468, 99471, 99475 – Initial In-Patient Neonatal Critical Care. When a patient transfers off of NICU or CICU to a regular medical floor but returns 7 days later for a complication, new problem or...

Scenario: Cathie Wilde, RHIA, CCS, Vice President of Coding Services A twenty-five year old woman who is 34 weeks pregnant is admitted for mild pre-eclampsia. Treatment for pre-eclampsia is successful but during course of the admission the patient develops other pregnancy complications including thrombocytopenia, oligohydramnios and painful diastasis recti....

Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education Situation: We always strive for completeness of clinical documentation. It is important to remind providers and practice managers to heed a warning from an OIG initiative; the OIG has announced their intent to audit healthcare organizations receiving meaningful use payments as part of the...

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding Discharge diagnoses listed in the discharge summary are pneumonia and sepsis present on admission. The diagnostic statement of pneumonia is documented throughout the medical record. However, the diagnostic statement of sepsis is a one time diagnostic statement in the discharge summary only. If in fact, both...

Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education Situation: Many facilities have had payments retracted by a payer over a non-attested or unsigned operative report. This is easily overlooked but should be on the priority list to ensure a service, be it an operative or clinic encounter (E/M), is in fact, billable, can come down to the...

Scenario: Cathie Wilde, RHIA, CCS, Vice President of Coding Services A 56 year old male presents to the emergency room with alcohol withdrawal after discontinuing alcohol 24 hours prior to presentation. He is placed on CIWA protocol and admitted to the hospital. The attending physician notes in the history that the patient has a diagnosis of alcoholism for over...

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?

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...

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...

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...

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...

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...

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...

Case Scenario: A 90 year old patient is admitted to the hospital with community acquired pneumonia. During the course of hospitalization, the patient develops some aphasia and a stroke is suspected. A CT scan is inconclusive and a MRI is unable to be done as the patient has a pacemaker. The physician signs out the final diagnoses as: community acquired pneumonia, TIA vs....

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding Take a moment to think about the physician queries you initiated or thought about initiating this week, specifically, those for abnormal lab results without a documented corresponding diagnosis. An example is a patient that underwent a colectomy; their pre-op HCT was 40 which decreased to 30 postoperatively....

Scenario: Cathie Wilde, RHIA, CCS, Vice President of Coding Services A patient was seen in the ER previously for a foot laceration occurring after stepping on glass while barefoot. The wound was sutured at the time. He now is admitted to the hospital three days later for treatment of foot cellulitis. Question: What is the Principal Diagnosis – complicated open wound...

Lynn Salois, RHIT, CCS, CDIP, Director of Coding Coding a medical record with incomplete documentation jeopardizes coding accuracy and negatively impacts reimbursement. However, sometimes real world situations prohibit Coding Managers from adhering to best practice standards. In the following scenario the discharge summary provided clarifying documentation; leading...

Cathie Wilde, RHIA, CCS, Vice President of Coding Services A forty-six year old patient arrives in the emergency room with chief complaint of confusion as described by patient’s spouse. A thorough work up is undertaken including blood work, radiological testing and a neurology consult. No etiology for the confusion is identified. The attending physician documents the...

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding Clinical Documentation Improvement Managers (CDIMs) continually monitor the success of their healthcare organization’s CDI program. The metrics they use commonly include volume of queries issued, query success, case mix data, severity of illness, and risk of mortality data. However, there is another critical...

Cathie Wilde, RHIA, CCS, Vice President of Coding Services It is important that your coding staff identify and code all pertinent secondary diagnoses that meet additional diagnoses criteria (as outlined by Coding Clinic, 4Q 2008, p. 305-306). In this month’s case, the identification of another secondary diagnosis meant an extra $22,000 in hospital revenue.More than...

Cathie Wilde, RHIA, CCS, Vice President of Coding Services Do the diagnosis codes that you submit on your claims support medical necessity? When you are coding patient encounters, do you assign diagnosis code(s) based only the final diagnosis documented by the provider, or do you review the record for chronic conditions that are being followed and should also be...

Strong communication between clinical documentation specialists (CDS) and clinical coders is vital to the success of any clinical documentation improvement program. But additional benefits may be gained through ongoing exchange between these two teams. Here’s a real-world example. Situation: In reviewing the medical record, the coder notes disconnect between the physician...

Cathie Wilde, RHIA, CCS, Vice President of Coding Services A sixty-two year old patient is seen in the emergency room complaining of rectal bleeding. His HCT is 24 and his platelet count is 38,000. The admitting diagnosis is GI bleed. Makes sense. However, per the history and physical, the patient has a history of a bleeding arteriovenous malformation and...

Situation: Lynn Salois, RHIT, CCS, CDIP, Director of Coding In reviewing the medical record the coder notes disconnect between the physician documentation and the CDS documentation. Initial physician documentation indicates pneumonia with later documentation indicating acute bronchitis. The CDS worksheet indicates acute bronchitis. Was the pneumonia ruled out? Did...

Luisa Dileso, RHIA, MS, CCS, Director of Coding Education Clinical coders are often sequestered within health information management (HIM) and incented to only code…not expand their horizons by keeping abreast of nationwide healthcare initiatives. But is this the best management approach? Situation: Several coders were breaking for lunch and an important conversation...

Lynn Salois, RHIT, CCS, CDIP, Director of Coding An elderly patient with a past medical history of CHF presents to the hospital with dyspnea and hyponatremia. Review of the history and physical indicates the patient’s daily Lasix dose was increased recently. What to do? Dig deeper! Upon further review, progress notes revealed that the patient has been non-compliant...

Luisa Dileso, RHIA, MS, CCS, Director of Coding Education Recently, an inpatient coding validation audit was scheduled to be performed for a MRA client hospital. However clinical program passwords and system access had not been set up or tested. We simply could not get access to the medical record information we needed to conduct the work. Consequently, the review...

Cathie Wilde, RHIA, CCS, Vice President of Coding Services An 88 year old patient was admitted to the hospital after suffering a cerebral infarct. After review of the record, code 434.91 was assigned as the Principal Diagnosis along with several other chronic condition codes resulting in a DRG of 066 – Intracranial Hemorrhage or Cerebral Infarction without CC/MCC. No...

Luisa Dileso, RHIA, MS, CCS, Director of Coding Education So the big question is, “How do I mitigate that drop in productivity?” You could hire an outsourcing company to provide coders through the transition. If you choose this option, go ahead and secure your contract now. Coding companies also expect an increase in work, and therefore demand, over the next two...

So the big question is, “How do I mitigate that drop in productivity?” One answer is to hire more coders. However, you can’t find them now – never mind when the demand spikes for I-10. Here is tip #2 of five in our series to improve coder productivity and accuracy. You’ll see immediate results while also preparing for your long-term needs! Tip #2: Make the Most of Your...

Luisa Dileso, RHIA, MS, CCS, Director of Coding Education ICD-10 is around the corner and many sources are predicting an initial drop in coder productivity of up to 50 percent. This will be followed by an ongoing drop in productivity of 10-20 percent. In fact, a former HIM Director from Canada said her coders were never as productive in ICD-10 as they were in ICD-9....

Luisa Dileso, RHIA, MS, CCS, Director of Coding Education Not the most exciting project and perhaps the most underestimated is the redesign of forms to accommodate the transition to ICD-10. Those of particular concern are those critical for clinical documentation by doctors, nurses, ancillary departments and others. Beware, this will take much longer and cost much...