Robert S. Gold, MD, writes about the significant changes in documentation needs for diseases of the brain and how this can affect patient data, as well as the treatment needs of the patients both during a hospital stay and afterward.
Anny Pang Yuen, RHIA, CCS, CCDS, CDIP and Laurie Prescott, MSN, RN, CCDS, CDIP discuss how for the past few years, healthcare professionals have focused on ICD-10 preparation, and while prep work paid off and the transition has been largely successful, facilities are experiencing a few bumps as their focus shifts from preparation to improvement of clinical documentation and coding.
E/M services resulted in a projected $4.5 billion in improper Medicare payments in 2014, according to the April 2016 Medicare Quarterly Compliance Newsletter, accounting for 9.3% of the overall Medicare fee-for-service improper payment rate.
Pregnant patients with other health issues can lead to complicated coding scenarios. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the clinical documentation necessary to identify certain complications and how coders can report these diagnoses. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Once you have set up your free registration, you can log in and access this article by clicking here.
CMS has proposed a new drug payment model that could impact providers nationwide. Jugna Shah, MPH, reviews the multiple stages of the rule and how providers can comment to CMS about the proposed changes.
Q: Can CPT® code 76700 (ultrasound, abdominal, real time with image documentation; complete) be coded with 76770 (ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real time with image documentation; limited) on the same date of service during the same session?
Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer, explains how under the Comprehensive Care for Joint Replacement, acute care hospitals in selected geographic areas assume quality and payment accountability for retrospectively calculated bundled payments for lower extremity joint replacement episodes, and how this now requires a CDI evolution.
Q: We are having trouble determining how to assign a code for a pressure ulcer that begins as a Stage I concern that is present on admission (POA) but advances during the patient’s stay to a Stage II or a Stage III. Coding Clinic, Fourth Quarter 2008, p. 194, tells us that even if the ulcer advances it would still be coded as POA, but would even an advanced stage still be considered POA?
An infographic newly released by CMS guides healthcare providers toward better assessing, addressing, and maintaining progress since ICD-10 implementation. Identifying key performance indicators and creating baselines for KPI analysis are important steps in tracking progress, says CMS.
