An anesthesia provider faces plenty of challenges: cancelled anesthesia, failed medical direction, monitored anesthesia care, time issues, invasive line placement rules, and start/stop times. Judy A. Wilson, CPC, CPC-H, CPCO, CPC-P, CANPC, CPC-I, CMRS, reviews some of the common challenges coders face when reporting anesthesia services.
Chronic kidney disease (CKD) is the permanent alteration in the kidney’s ability to perform filtration and reabsorption functions. Patients with CKD can come into an outpatient clinic or may be admitted as an inpatient, either for the CKD or some other condition. Debra Lawson, CPC, PCS, and Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, explain the ICD-9-CM and CPT ® coding for CKD.
In coding, sometimes it really is brain surgery and coders need a strong understanding of the anatomy of the skull and brain in order to correctly report diagnoses and procedures. Cynthia Stewart, CPC, CPMA, CPC-H, CPC-I, discusses the anatomy of the brain and skull and guides coders through some brain surgery procedures.
Cardiac catheterization is a common procedure performed to study cardiac function and anatomy and to determine if a patient is a candidate for intervention. Terry Fletcher, CPC, CCC, CEMS, CCS-P, CCS, CMSCS, CMC, and Jillian Harrington, MHA, CPC, CPC-P, CPC-I, CCS-P, MHP, explain how to code the different catheterization procedures.
Coders and clinicians often seem to speak different languages. What a clinician considers important information may not be what a coder needs to assign the correct code. Clinicians may not document a piece of information that is vital to the coder. Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC, Joseph Nichols, MD, and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, explain how clinicians and coders can work together to improve communication.
When a physician determines the patient has a coronary artery blockage, the physician can choose from several options for treating the patient, depending on exactly what is wrong. John F. Seccombe, MD, and Betty Johnson, CPC, CPC-I, CPC-H, CPCD, CCS-P, PCS, CCP, CIC, RMC, discuss invasive and non-invasive treatments, as well as the heart’s anatomy.
To correctly assign codes for any surgical procedure, coders need to have an operative (OP) report. But simply having an OP report isn’t enough. Coders also must be able to read the OP report and pick out the important information. Lynn Pegram, CPC, CEMC,CPC-I, CGSC, breaks down the OP report to help coders find the information they need.
Coders will need more information to correctly assign fracture codes in ICD-10-CM, but don’t fear. Most of that information is already in the medical record. Robert S. Gold, MD, Sandy Nicholson, MA, RHIA, and Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, walk through what you need to know to code fractures in ICD-10-CM
The AMA added a total of 60 new codes throughout the surgery section of the 2012 CPT ® Manual , 18 of which appear in the cardiovascular and respiratory system subsections. The AMA also revised 86 codes and deleted 48 codes in the surgery section. Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, and Christi Sarasin, CCS, CCDS, CPC-H, FCS, highlight the significant changes for 2012.
In addition to updating procedures for 2-midnight rule reviews, the 2016 OPPS final rule includes new guidance on coding and billing issues, including reporting certain CT scan services. Jugna Shah, MPH, examines the changes and what providers need to do before 2016.
