CMS recently released two ICD-10-PCS codes, effective April 1, to describe the introduction or infusion of therapeutics, including vaccines for COVID-19 treatment.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , writes that it’s not unusual for an outpatient coder to advance their career by diving into inpatient coding. When deciding to learn about ICD-10-PCS, it’s important to first understand the basics and compare and contrast ICD-10-PCS and CPT. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Inpatient coders know that clinical indicators for certain conditions frequently require greater completeness or specificity in ICD-10-CM for which a concurrent or retrospective query is often required. This article will review clinical indicators and query opportunities for common respiratory conditions such as pneumonia, respiratory failure, and asthma.
One of the biggest components of a leader’s role is to track, trend, and report on the department’s performance. Key performance indicators can range in complexity depending on the needs of the organization, but all are imperative for proving the success of a CDI or coding program.
Q: I’ve been told that if there are clinical indicators to support that chronic kidney disease (CKD) is the etiology of a patient’s hypertension, an ICD-10-CM code from category I15.- (secondary hypertension) would be assigned. Since codes from category I12.- (hypertensive chronic kidney disease) also capture CKD with hypertension, what is the best code category to be reporting from?
Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM, says that when reporting sepsis in ICD-10-CM, it’s important that evidence of sepsis is found throughout the body of a patient’s medical record. A clinical validity query may be necessary if the provider confirms the diagnosis of sepsis, but clinical evidence is lacking in the documentation.
Susan Belley, M.Ed., RHIA, CPHQ, and Audrey Howard, RHIA, write that a majority of inpatients during this omicron surge are admitted for reasons other than COVID-19 and are incidentally found to be COVID-19-positive—making this an opportune time to review ICD-10-CM reporting for COVID-19 as a secondary diagnosis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: If a physician documents a patient as HIV positive, should the ICD-10-CM code Z21 be reported? What about if they document the patient is HIV positive with an HIV-related illness—would that be reported with ICD-10-CM code B20?
The Centers for Disease Control and Prevention (CDC) recently released multiple addenda with new tabular and index instructions and updates to the ICD-10-CM Official Guidelines for Coding and Reporting to complement the updated ICD-10-CM code set to become effective April 1.
Departmental silos are prevalent in the healthcare world and can lead to unvoiced frustrations and counterproductive work. This article reviews how different organizations have various approaches to breaking down these walls.
