Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, explains the significance of reporting social determinants of health (SDoH) with examples related to health literacy, environmental factors, and living conditions.
Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, explains the significance of reporting social determinants of health (SDoH) with examples related to health literacy, environmental factors, and living conditions.
Learn about the challenges faced and collaborative opportunities encountered by one organization when it began the process of improving its observed-over-expected mortality ratio.
The term “stroke” or cerebrovascular accident (CVA) indicates an interruption in blood flow to the brain. Nancy Reading, RN, CPC, CPC-P , reviews strokes and explains how coders should report them and their treatment in ICD-10-CM and ICD-10-PCS.
Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS, describes how coding reviews provide an opportunity to conduct a thorough compliance review that not only addresses components of the coding process, but also the integrity of the patient’s record.
Encephalopathy refers to any disease of the brain that alters its function or structure. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG, breaks down documentation requirements and ICD-10-CM coding for toxic, acute, and chronic encephalopathy.
Physicians have found ways to treat many congenital defects in utero, enabling the neonate to be born without defects. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, details ICD-10-CM coding for common birth defects, and ICD-10-PCS and HCPCS Level II coding for their treatment.
Key performance indicators are used by organizations to monitor the progress of CDI initiatives. Waldo Herrera, MD, MBA, MSc, FACP, SFHM, CHCQM-PHYADV , describes performance metrics that professionals at his facility use to track revenue cycle performance and opportunities for improvement.
Revenue cycle leaders reported denials management as their most time-consuming revenue cycle task, followed by prior authorizations, according to a new survey by AKASA.
Spinal fusions can effectively eliminate pain and restore stability to the spine. Learn how to apply ICD-10-PCS codes and guidelines for spinal fusions and related procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: A patient with fatty liver disease undergoes ultrasound cavitation. What diagnoses are treated using ultrasound cavitation and how is the procedure reported in ICD-10-PCS?
Pneumonia is the eighth-leading cause of death in the U.S. This article outlines signs and symptoms of respiratory infection, pneumonia etiologies, and ICD-10-CM coding for complex pneumonia. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS recently published its evaluation of New Technology Add-on Payment (NTAP) applications and proposed revisions to NTAP eligibility criteria in its fiscal year (FY) 2024 IPPS proposed rule.
The gap between clinical reality and coding terminology can be addressed by empowering coders to use clinical judgment. Merle Zuel, RN, CCDS , discusses when it is appropriate for coders to interpret provider documentation and use their clinical judgment to code it in a certain way.
What may be considered a simple task, such as confirming present on admission status, can be complicated by discrepancies between coding and quality reporting criteria. Kate Siemens, RN, CMSRN, CCDS , outlines the ways in which coding and quality metrics do not align.
CMS released the fiscal year (FY) 2024 IPPS proposed rule on April 10. The document contains proposals for 395 new, 12 revised, and 25 invalidated ICD-10-CM codes.
Kerri Swart, RN, CCRN, CCDS, writes about how a previously 100%on-site CDI program shifted to remote work and maintained productivity and education standards.
What may be considered a simple task, such as confirming present on admission status, can be complicated by discrepancies between coding and quality reporting criteria. Kate Siemens, RN, CMSRN, CCDS , outlines the ways in which coding and quality metrics do not align.
Spinal fusions can effectively eliminate pain and restore stability to the spine. Learn how to apply ICD-10-PCS codes and guidelines for spinal fusions and related procedures.
Coding audits are often a source of irritation in small and large practices alike. This article covers common misconceptions about the auditing process and offers tips from experts on how to correct them.
Congestive heart failure (CHF) is used ubiquitously in medical records. Nancy Reading, RN, CPC , breaks down CHF types and pathophysiology, and discusses ICD-10-CM coding for the condition.
Patients with Alzheimer’s disease and related dementias have higher readmission rates than the general geriatric population, according to a retrospective cohort study published in JAMA Network Open .
Approximately 1.7 million adults in America develop sepsis each year, according to the Centers for Disease Control and Prevention. Review documentation requirements and ICD-10-CM coding for severe sepsis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS proposes 395 new, 12 revised, and 25 invalidated codes for implementation in October, according to the 2024 IPPS proposed rule. Read up on the changes which, if finalized, will have an impact on reimbursement and documentation.
CMS’ quality measures rank hospital mortality data as better than, no different than, or worse than the national mortality rate. JoAnne Mullins, DNP, MSN, RN, CCDS , describes how to perform quality reviews targeting missed coding opportunities and other factors that influence mortality data.
Functional and structural disorders, infections, and irritations of the large intestine can cause debilitating digestive complications that require surgical intervention. Review ICD-10-PCS coding for colectomy and ostomy procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
When reporting ICD-10-CM codes for encephalopathy with comorbidities, coders must carefully review documentation to determine which conditions are separately reportable. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG , breaks down ICD-10-CM reporting guidance for complex cases of encephalopathy.
CMS released the fiscal year (FY) 2024 IPPS proposed rule on April 10, with proposals for the annual ICD-10-CM/PCS code update and increases to hospital payment rates. The rule also introduces new quality measures aimed at reducing health equity gaps.
Approximately 1.7 million adults in America develop sepsis each year, according to the Centers for Disease Control and Prevention. Review documentation requirements and ICD-10-CM coding for severe sepsis.
Functional and structural disorders, infections, and irritations of the large intestine can cause debilitating digestive complications that require surgical intervention. Review ICD-10-PCS coding for colectomy and ostomy procedures.
Expanding into psychiatric units or facilities is a step that CDI programs may take because of their current patient population, a newly acquired center, or just another chance to improve their risk adjustment factor (RAF) score.
Encephalopathy refers to any disease of the brain that alters its function or structure. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG , breaks down documentation requirements and ICD-10-CM coding for toxic, acute, and chronic encephalopathy.
Nearly 80% of healthcare organizations are collecting data on social determinants of health (SDoH), or non-clinical factors that affect health, including family and home life, education, employment, and food insecurity, according to a new AHIMA survey.
Clinical documentation and ICD-10-CM coding terminology for neonatal conditions do not always match. Review documentation requirements and ICD-10-CM coding guidelines for reporting common neonatal diagnoses, as well as advice for querying pediatric healthcare providers.
Cerebrovascular accidents (CVA) are the fifth-leading cause of death and a leading cause of disability in the U.S., according to the Centers for Disease Control and Prevention. Review ICD-10-CM coding for CVA and ICD-10-PCS coding for surgical interventions used to open blocked arteries. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Findings from a recent medical record review published by JAMA Network Open show that physical assaults are often miscoded as accidents. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , breaks down ICD-10-CM coding for specific details about an injury or health event.
Q: A 4-year-old managing lissencephaly, hypotonia, and dysphagia with aspiration of secretions presents with fever and tachypnea. A chest x-ray shows right lower lobe infiltrates. Would it be appropriate to query the provider to confirm a diagnosis of pneumonia?
Postoperative mortality rates among Medicare beneficiaries are associated the characteristics of patients’ neighborhoods and the hospitals where they received treatment, according to a study published in JAMA Network Open in January.
As healthcare systems look to replicate successful CDI programs outside of large complex community or academic health centers, there are unique considerations for rural settings.
Chronic obstructive pulmonary disease (COPD) was the sixth-leading cause of death in the U.S. in 2020 with 152,657 deaths, according to the Centers for Disease Control and Prevention. Read up on ICD-10-CM coding for different types of COPD including emphysema and chronic bronchitis. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Jorde Spitler, RN, CDI manager at Dayton Children’s Hospital, describes key considerations for documentation review, querying, and ICD-10-CM coding in a pediatric acute care setting.
Encephalopathy refers to any disease of the brain that alters its function or structure. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG , breaks down documentation requirements and ICD-10-CM coding for toxic, acute, and chronic encephalopathy.
Chronic obstructive pulmonary disease (COPD) was the sixth-leading cause of death in the U.S. in 2020 with 152,657 deaths, according to the Centers for Disease Control and Prevention. Read up on ICD-10-CM coding for different types of COPD including emphysema and chronic bronchitis.
Robotic and computer-assisted surgical procedures are still considered new technology despite having been used in the U.S. for many years. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG , unpacks ICD-10-PCS coding for surgeries performed using specialized software and robotic technology.
Laura Roberts, BSN, RN, CCDS , describes how to perform internal reviews that target Patient Safety Indicators, hospital-acquired conditions, and other quality indicators.
Adhere to ICD-10-PCS guidance for reporting multiple procedures and procedural components when coding for wound debridement and skin grafting. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Robotic and computer-assisted surgical procedures are still considered new technology despite having been used in the U.S. for many years. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG , unpacks ICD-10-PCS coding for surgeries performed using specialized software and robotic technology.
There is no single query format every organization uses. Though guidelines exist, each CDI program and its leaders must ultimately determine how to maintain compliance.
Coding and CDI professionals should understand disease processes for common inpatient diagnoses. Ronald Singell, RN, BSN, CCDS , writes about clinical indicators of disease for diabetic ketoacidosis, gastrointestinal hemorrhage, and sequential organ failure.
The Office of Inspector General (OIG) recently released its annual report detailing its list of top unimplemented recommendations for 2022. The agency recommends that CMS increase scrutiny of inpatient hospital claims for severe malnutrition and other diagnoses that are vulnerable to upcoding.
Pneumonia is a common infection of the lungs that can be life-threatening. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , breaks down ICD-10-CM/PCS coding for this infectious disease and its treatment.
Obesity has grown into a global epidemic with significant social and economic consequences. Review ICD-10-CM coding for obesity and other weight-related conditions, and ICD-10-PCS coding for surgical interventions used to maintain a healthy weight.
If a urinary tract infection is left untreated, it can spread to other organs and cause sepsis and septic shock. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , breaks down ICD-10-CM coding for this life-threatening diagnosis.
Stacy Reck, MBA, RHIA, CDIP , and Ashley Wells, MN, RN, CMSRN, CCDS , describe common reasons for clinical validity denials and strategies they use to defend against them. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Auditors see assignment of certain MS-DRGs as a red flag and most often will pull these encounters for review. Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , describes these MS-DRGs and offers advice for ensuring accurate reporting of a principal diagnosis.
A retrospective medical record review published in JAMA Network Open in December found that nearly one-third of intentional firearm injuries resulting in emergency department admissions were inaccurately coded in ICD-10-CM as accidents.
Trey La Charité, MD, FACP, SFHM, CCS, CCDS , outlines benefits that come with being a physician advisor and how coding and CDI professionals can reiterate these to physicians who are interested in taking on this role.
Paraneoplastic syndrome is a rare condition that results from an immune system response to a neoplasm. In this article, Sarah Nehring, RHIA, CCS, CCDS , breaks down ICD-10-CM/PCS coding for paraneoplastic syndrome of the nervous system.
CMS recently released Medicare Claims Processing Transmittal 11685 revising language to make three revenue codes for inpatient hospital services allowable for payment under Medicare Part B and adding COVID-19 to its list of preventive services.
Review key policy updates introduced in the 2023 IPPS final rule, including an increase in operating payments, changes to New Technology Add-on Payment designations, MS-DRG updates, and introduction of a birthing-friendly hospital designation. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
If a urinary tract infection is left untreated, it can spread to other organs and cause sepsis and septic shock. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , breaks down ICD-10-CM coding for this life-threatening diagnosis.
Paraneoplastic syndrome is a rare condition that results from an immune system response to a neoplasm. In this article, Sarah Nehring, RHIA, CCS, CCDS , breaks down ICD-10-CM/PCS coding for paraneoplastic syndrome of the nervous system.
A great deal of change has occurred over the past three years in healthcare, and every organization nationally is feeling the financial burden in the wake of COVID-19 and recent natural disasters.
While laser interstitial thermal therapy (LITT) is not new, the expansion of its use for diagnoses beyond brain tumors can help a new patient population. Shelley C. Safian, PhD, RHIA, HCISPP, CCS-P, COC, CPC-I , describes how LITT is documented and reported in ICD-10-PCS.
The 2023 ICD-10-CM Official Guidelines for Coding and Reporting include new reporting guidance for neoplasms, care complications, social determinants of health, and more. Review significant updates to the guidelines, which took effect October 1. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Healthcare professionals often struggle to define the role of CDI in their organization. Marlene Goodwin-Esola, MSN, RN-C, CV , clarifies the role of CDI specialists and professionals in related disciplines who contribute to documentation improvement efforts.
The average patient length of stay in hospitals has increased by 19.2% in 2022 compared to 2019 levels, the American Hospital Association said, citing data from Strata Decision Technology. For patients awaiting discharge to post-acute care settings, the increase is nearly 24%.
The principal diagnosis is key to prioritizing subsequent reviews, identifying potential quality measure inclusion, and pinpointing query opportunities. Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC , breaks down guidance for selecting the principal diagnosis.
Vaccinations are simple and effective ways of protecting individuals against harmful diseases. Review ICD-10-CM/PCS coding for vaccines administered during inpatient admission. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Clinical quality measures are tools used by healthcare professionals to measure or quantify processes and outcomes. Audrey Howard, RHIA, and Susan Belley, RHIA, CPHQ, describe documentation elements that affect quality metrics and how to incorporate them into an audit workflow.
Coded housing instability is linked to higher hospital admission rates for mental disorders, longer inpatient stays, and substantial healthcare costs, according to a study recently published in JAMA Network Open .
Vaccinations are simple and effective ways of protecting individuals against harmful diseases. Review ICD-10-CM/PCS coding for vaccines administered during inpatient admission.
Acute hospital care at home is reimbursed the same as if the patient was physically an inpatient in a hospital, with the same documentation requirements, quality measures, and medical necessity guidelines. Learn how strengthening CDI's role in these programs can help support their success.
While laser interstitial thermal therapy (LITT) is not new, the expansion of its use for diagnoses beyond brain tumors can help a new patient population. Shelley C. Safian, PhD, RHIA, HCISPP, CCS-P, COC, CPC-I , describes how LITT is documented and reported in ICD-10-PCS.
The terms “admission” and “observation” are often confused. Dawn Valdez, RN, LNC, CCDS, CDIP , distinguishes between these terms and evaluates ICD-10-CM coding for patients who begin in observation and are later admitted to the hospital for more intensive care.
Quality metrics are complex, and it takes deep knowledge to understand their intricacies. Audrey Howard, RHIA, and Susan Belley, RHIA, CPHQ , describe commonly overlooked documentation elements that can affect quality metrics and outline how to incorporate these elements into an audit workflow.
The severity and length of post-COVID-19 symptoms has been a topic of study almost ever since the pandemic began. In a new study involving patients with significant respiratory disability following hospitalizations for COVID-19, daily supervised pulmonary rehabilitation was associated with significant improvement in exercise tolerance and quality of life.
Cardiorenal syndrome refers to acute or chronic dysfunction of the heart or kidneys that causes dysfunction in the other organ. Review ICD-CM coding for heart and kidney failure and the physiological impact that dysfunction in one system has on the rest of the body. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
ICD-10-CM coding for respiratory illnesses requires a solid understanding of clinical indicators and coding guidelines. Review documentation and guidance for reporting acute respiratory distress syndrome, asthma, and pediatric multisystem inflammatory syndrome. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Lena Wilson, MHI, RHIA, CCS, CCDS , takes a deep dive into the CDI/coding reconciliation process and outlines tips that coders and CDI professionals can apply to improve this process.
Coding for newborn services can be complicated due to detailed examinations and therapeutic treatments performed after delivery. Sarah Nehring, RHIA, CCS, CCDS , breaks down ICD-10-CM coding for newborn encounters and reviews new codes for newborn apnea that took effect October 1.
As the shift to outpatient care has accelerated, likely due to COVID-19, inpatient volumes continue to remain below pre-pandemic levels for hospitals and health systems this year, according to Kaufman Hall’s 2022 State of Healthcare Performance Improvement report.
Coding for newborn services can be complicated due to detailed examinations and therapeutic treatments performed after delivery. Sarah Nehring, RHIA, CCS, CCDS , breaks down ICD-10-CM coding for newborn encounters and reviews new codes for newborn apnea that took effect October 1.
Kathy Shumpert, MSN, RN, CCDS, writes about the evolution of the denials and appeals process at her facility and discusses tactics to improve communications and efficiency.
Coding and billing professionals must ensure that medical record information is accurate, up to date, and compliant. In this article, Holly Cassano, CPC, CRC , defines late entries, corrections, and addendums, and explains the proper methods used to alter health records while maintaining Medicare compliance.
The terms “admission” and “observation” are often confused. Dawn Valdez, RN, LNC, CCDS, CDIP, distinguishes between these terms and evaluates ICD-10-CM coding for patients who begin in observation and are later admitted to the hospital for more intensive care.
A recent medical record review published in the Journal of the American Medical Association Network Open found that between October 1, 2021, and January 31, 2022, providers used ICD-10-CM code U09.9 (post-COVID-19 condition, unspecified) to identify a multitude of post-acute conditions brought on by COVID-19.
Stroke, or cerebrovascular accident (CVA), is the fifth leading cause of death in the U.S. and the second leading cause of death worldwide, according to the Centers for Disease Control and Prevention. Unpack clinical documentation and ICD-10-CM coding for various types of CVA. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
