Social determinants of health ICD-10-CM codes have become more of a hot topic in the CDI world over the past few years. Review guidance for reporting personal circumstances such as income, wealth, and education that impact health and wellbeing.
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.
Coders must be familiar with ICD-10-CM reporting guidelines for common neurological conditions. This article unpacks recent updates to the nervous system chapter of ICD-10-CM including 14 new codes for autonomic conditions and fatigue syndromes. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
A properly calibrated audit tool is key to uncovering educational opportunities for coding and CDI professionals. Dawn Valdez, RN, LNC, CDIP, CCDS, outlines questions for determining an audit focus and for querying providers when documentation is insufficient to support medical necessity.
Respiratory failure occurs when the body is unable to provide oxygen to or remove carbon dioxide from the body. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , breaks down documentation and ICD-10-CM coding for acute and chronic respiratory failure.
A recent review of inpatient medical records published in the Journal of the American Medical Association Network Open from 463 hospitals found significant increases in pregnancy-related complications and maternal death during the COVID-19 pandemic.
Coders must be familiar with ICD-10-CM reporting guidelines for common neurological conditions. This article unpacks recent updates to the nervous system chapter of ICD-10-CM including 14 new codes for autonomic conditions and fatigue syndromes.
Pregnancy causes changes to the immune system that increase the risk of infection and sepsis during pregnancy, labor, and the puerperium. Sarah Nehring, BS, RHIT, CCS, CCDS , analyzes ICD-10-CM documentation and coding for sepsis after childbirth.
Coders must be familiar with updates to the ICD-10-CM/PCS code sets for fiscal year 2023 . Audrey Howard, RHIA , reviews new codes and reporting guidelines for dementia, care complications, and vascular procedures as well as updates to MS-DRGs.
The 2023 ICD-10-PCS code update includes 331 new codes and 64 code deletions that take effect this week. This article takes a close look at new ICD-10-PCS codes and guidelines for amputations, laser ablation, and aortic valve replacements. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Audits are crucial to helping CDI and coding teams stay up to date with the fast pace of medicine and continual changes to coding guidelines. Dawn Valdez, RN, LNC, CDIP, CCDS , writes about best practices for auditing and application of audit findings .
Hospitals and health systems have recently seen some of the worst margins since the start of the COVID-19 pandemic, according to Kaufman Hall’s National Hospital Flash report .
Q: Does documentation for a drug or alcohol use disorder need to specifically state “in remission,” or is a history of drug use sufficient to classify the condition as in remission?
A rise in patient acuity during the COVID-19 pandemic has contributed to significant growth in hospital costs, according to a recent report by the American Hospital Association (AHA).
Social determinants of health such as economic stability and access to education significantly impacting health outcomes. Kim Conner, BSN, RN, CCDS, CCDS-O , outlines potentially confusing ICD-10-CM guidelines and documentation challenges that complicate coding for social determinants.
Endometriosis is a common gynecological condition that occurs when the tissue that lines the inside of the uterus grows outside of the uterus. Brush up on ICD-10-CM coding for the condition and ICD-10-PCS coding for surgical procedures used to treat it. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Debridement is used to treat serious or chronic wounds that do not heal with standard treatment. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBG , describes five types of debridement and how to report these procedures in ICD-10-PCS.
Social determinants of health such as economic stability and access to education significantly impacting health outcomes. Kim Conner, BSN, RN, CCDS, CCDS-O , outlines potentially confusing ICD-10-CM guidelines and documentation challenges that complicate coding for social determinants.
Coders must be familiar with updates to the ICD-10-CM/PCS code sets for fiscal year 2023 . Audrey Howard, RHIA , reviews new codes and reporting guidelines for dementia, care complications, and vascular procedures as well as updates to MS-DRGs.
Bronchus, lung, and lymph node biopsies are often performed via a bronchoscopic technique. Sarah Nehring, BS, RHIT, CCS, CCDS , breaks down ICD-10-PCS coding for brush, transbronchial fine needle aspiration, and transbronchial forceps biopsies.
A recent audit conducted by the Office of Inspector General (OIG) found that Cariten Health Plan Inc. in Knoxville, Tennessee, received at least $9.2 million in net overpayments from 2016 to 2017 for incorrectly submitting selected high-risk diagnosis codes.
Q: Why isn't a secondary diagnosis of morbid obesity considered a complication or comorbidity (CC) by CMS? What obesity diagnoses are classified as CCs by CMS?
Malnutrition includes undernutrition, inadequate vitamins or minerals, overnutrition, obesity, and diet-related noncommunicable diseases. Inpatient coders must be familiar with clinical criteria and ICD-10-CM coding for this condition as it is frequently the focus of clinical validation audits. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Inpatient coders have malnutrition on their mental list of diagnoses at risk of audits. Learn how to effectively work with dieticians and CDI staff to ensure accurate documentation and ICD-10-CM coding for malnutrition.
Bronchoscopy is often performed in conjunction with other therapeutic procedures for the treatment of lung problems. Sarah Nehring, BS, RHIT, CCS, CCDS , breaks down ICD-10-PCS coding for bronchoscopy with bronchoalveolar lavage and suction of a mucus plug.
A spinal fusion is used to permanently connect two or more vertebrae, eliminating motion between them. Read up on ICD-10-PCS guidance for reporting spinal fusions based on key details in the operative note. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Q: When would you report an ICD-10-CM code from category I22 (subsequent ST elevation and non-ST elevation myocardial infarction [MI]) with a code from I21 (acute MI)?
CMS released the fiscal year (FY) 2023 IPPS final rule on August 1, increasing hospital payment rates by 4.3% and establishing three health equity-focused measures in hospital quality programs.
A spinal fusion is used to permanently connect two or more vertebrae, eliminating motion between them. Read up on ICD-10-PCS guidance for reporting spinal fusions based on key details in the operative note.
Reconciling CDI reviews and queries against final coding is an important but sometimes overlooked step. Use these expert tips to refresh or develop your organization's CDI and coding reconciliation process.
Twenty-five percent of hospitalized Medicare patients experience patient harm, and 43% of those harm events could have been prevented, according to a recent Office of Inspector General (OIG) report.
Determining the most specific ICD-10-PCS code for a procedural service can be tricky given that there are 34 character values and over 78,000 ICD-10-PCS codes for 2022. This article breaks down potentially confusing ICD-10-PCS guidelines for obstetric and cardiovascular procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Sepsis and systemic inflammatory response syndrome are historically difficult to document and report in ICD-10-CM. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , breaks down sepsis definitions and outlines a process for query creation.
Hospital coders must be able to determine the reason for an admission and to differentiate conditions present on admission (POA) from those that develop during an inpatient stay. Learn how to effectively decipher documentation to identify the principal diagnosis and conditions that were POA.
Peoples Health Network received an estimated $3.3 million in overpayments between 2015 and 2016 for incorrectly billing ICD-10-CM codes from high-risk groups, according to a recent audit by the Office of Inspector General (OIG).
A handful of new ICD-10-CM/PCS codes took effect April 1. Read up on the updates and CMS’ process for implementing code changes biannually. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
In an industry that changes both quickly and frequently, keeping staff educated is important not only for your healthcare system, but for your employees’ professional growth. Catherine Sheika, BSN, RN, CCDS, writes about coding and team-building games that make even the driest topics more engaging.
Coders in acute care facilities must be comfortable assigning ICD-10-CM/PCS codes for abortions. Sarah Nehring, BS, RHIT, CCS, CCDS , breaks down ICD-10-CM/PCS codes for spontaneous and induced abortions and related complications.
by Kim Conner, BSN, RN, CCDS, CCDS-O In our ever-changing landscape of healthcare, quality and prevention continue to drive the way we deliver care to our patients. As a result, social determinants...
Sepsis and systemic inflammatory response syndrome are historically difficult to document and report in ICD-10-CM. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , breaks down sepsis definitions and outlines a process for query creation.
Cranial diagnoses present with varied symptoms and require an individualized approach to treatment. Brush up on documentation and ICD-10-CM/PCS coding for neuroendoscopy, posterior fossa decompression, and embolectomy/thrombectomy procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Coding a chart with a sepsis diagnosis requires careful attention to detail. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , reviews sepsis documentation, ICD-10-CM coding requirements, and quality measures for public reporting.
Hospitals have made avoiding and managing denials a top priority, but for many, their best efforts have yet to turn the tide. Take steps to address compliance concerns and reduce denial rates.
The Centers for Disease Control and Prevention recently released the fiscal year (FY) 2023 ICD-10-CM code set and ICD-10-CM Official Guidelines for Coding and Reporting , introducing new codes and guidance for reporting dementia, head injuries, and long-term drug therapy.
Correct present on admission (POA) identification and use of POA indicators is important, as these indicators directly affect how insurance providers and patients are billed. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , breaks down POA reporting requirements and payment implications.
Various ICD-10-CM/PCS and CPT codes may be used to report hospital services for the diagnosis and treatment of COVID-19. Review Q&As on appropriate coding for COVID-19 laboratory testing, comorbidities, and treatments.
Inpatient coding for brain surgery can be challenging as many approaches, techniques, and devices may be used to treat cranial abnormalities. Read up on reporting requirements and ICD-10-CM/PCS coding for craniotomies and deep brain stimulation (DBS). Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS recently released the fiscal year (FY) 2023 ICD-10-PCS code set and ICD-10-PCS Official Guidelines for Coding and Reporting . The ICD-10-PCS update includes several new codes for Destruction and Occlusion, and a new guideline for Detachment procedures of the extremities.
Q: What clinical criteria should coders use to support ICD-10-CM code assignment for upcoming 2023 dementia codes in category F02 (dementia in other diseases classified elsewhere)?
Various ICD-10-CM/PCS and CPT codes may be used to report hospital services for the diagnosis and treatment of COVID-19. Review Q&As on appropriate coding for COVID-19 laboratory testing, comorbidities, and treatments.
Ongoing labor shortages and a competitive hiring market are putting a strain on HIM departments. As competition for qualified staff increases, learn how HIM leaders can turn to a variety of short- and long-term fixes and even find opportunities for improvement.
Coding a chart with a sepsis diagnosis requires careful attention to detail. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , reviews sepsis documentation, ICD-10-CM coding requirements, and quality measures for public reporting.
Items eligible for CMS’ New Technology Add-on Payment (NTAP) often yield high reimbursement but are prone to charging, coding, and billing errors. Learn about the NTAP designation and its impact on coding and billing processes.
Approximately 37.3 million Americans have diabetes, and nearly 20% of them don’t know they have it, according to the Centers for Disease Control and Prevention. Review the signs and symptoms of diabetes and guidelines for reporting the condition in ICD-10-CM. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The establishment of mandatory sepsis protocols at all hospitals in New York state is estimated to have saved more than 16,000 lives between 2015 and 2019, according to End Sepsis.
A cesarean section is typically performed when complications from pregnancy make a traditional vaginal birth difficult. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I , breaks down ICD-10-CM coding for common labor and delivery complications, and ICD-10-PCS coding for cesarean deliveries.
Revenue leakage can be caused by a number of factors including late filings, inconsistent documentation, and inaccurate coding. Fran Jurcak, MSN, RN, CCDS, CCDS-O , describes proactive strategies that coding professionals can use to address mid-revenue cycle leakage.
Hospitalists coded a significantly higher proportion of Medicare beneficiaries as high severity compared to non-hospitalists, according to a study published in the Journal of the American Medical Association Health Forum .
CMS is proposing to hit pause on major changes to MS-DRG designations while considering numerous changes to quality reporting and value programs, according to the fiscal year 2023 IPPS proposed rule. Read up on CMS’ proposed updates, which will impact inpatient hospitals beginning October 1. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Aspiration pneumonia is a lung infection caused by inhaled oral or gastric contents. Alba Kuqi, MD, CCS, CDIP, CCDS, CRCR, CICA, CSCM , breaks down documentation and ICD-10-CM coding requirements for aspiration pneumonia.
CMS is proposing to hit pause on major changes to MS-DRG designations while considering numerous changes to quality reporting and value programs, according to the fiscal year 2023 IPPS proposed rule. Read up on CMS’ proposed updates, which will impact inpatient hospitals beginning October 1.
Approximately 37.3 million Americans have diabetes, and nearly 20% of them don’t know they have it, according to the Centers for Disease Control and Prevention. Review the signs and symptoms of diabetes and guidelines for reporting the condition in ICD-10-CM.
As a result of the pandemic, delivering consistent, quality CDI education has become more challenging. My hospital has been no exception, and although adapting has not been easy, it is doable.
Inpatient coders must be familiar with different types of denials such as those due to clinical validity concerns. Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , outlines components of a clinical validation denial and tools used to craft a clinical validation appeal.
CMS released the fiscal year (FY) 2023 IPPS proposed rule on April 18, 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 advancing health equity and improving maternal health outcomes.
Coding managers should not assume that they can review every coding guideline, Coding Clinic , or coding-related issue targeted by the Office of Inspector General. Review considerations for conducting focused internal and external audits. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Reviewing a sample of claims for clinical validity and coding accuracy can seem like a daunting task. Kaitlin Loos, RN, BSN, CDI auditor, and Molly Siebert, RHIA, CCDS, CDI specialist, describe their individualized review processes.
Nancy Treacy, MPH, RHIA, CDIP, CCS , describes her team’s experience implementing a streamlined audit process and offers advice to help others do the same. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
A recent audit conducted by the Office of Inspector General (OIG) projected that hospitals received $47.8 million in net overpayments from January 2018 through July 2019 for Medicare Part A claims that did not meet national requirements or contractor specifications for bariatric surgery.
Monitoring coding accuracy enables coding managers to spot error trends that could result in claim denials. Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS , describes two methods used to calculate coding accuracy based on a sample of claims.
Nancy Treacy, MPH, RHIA, CDIP, CCS , describes her team’s experience implementing a streamlined audit process and offers advice to help others do the same.
Inpatient coders must be familiar with different types of denials such as those due to clinical validity concerns. Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , outlines components of a clinical validation denial and tools used to craft a clinical validation appeal.
Electronic health records (EHR) hold all the important information about patients’ medical histories and demographics. Historically, however, they have tended to only include one indication of gender: the gender a patient was assigned at birth.
Anxiety disorders are the most common mental illness in the U.S., according to the National Institute of Mental Health Statistics. Shelley Safian, PhD, RHIA, CCS-P, COC, CIC , breaks down ICD-10-CM coding for common types of anxiety disorders and psychotherapy treatments used to manage them.
Joe Rivet, Esq., CCS-P, CPC, CEMC, CHC, CCEP, CHRC, CHPC, CICA, CPMA, CAC, CACO , describes how to use Office of Inspector General audit reports to identify areas at risk for noncompliance and how to organize targeted internal reviews.
It is estimated that as many as 1 in 500 adults may suffer from a cardiomyopathy, according to the Centers for Disease Control and Prevention. Review documentation considerations and ICD-10-CM coding for different types of cardiomyopathies. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Mechanical ventilation is a life-saving intervention used for acutely ill patients who cannot breathe on their own. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , evaluates medical terminology used to describe mechanical ventilation and breaks down ICD-10-PCS coding for this procedure.
CMS recently released three ICD-10-PCS codes, effective April 1, for the administration of fostamatinib (Tavalisse®)—an oral spleen tyrosine kinase inhibitor used to treat adults with low platelet count due to chronic immune thrombocytopenia.
Patients are often admitted for acute conditions and experience additional issues affecting their care and treatment plan during the encounter. Ashayla Stephens, MHA, RHIA, CCS , and Audrey Howard, RHIA , describe the process of validating multiple diagnoses documented within the health record. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
A recent audit conducted by the Office of Inspector General (OIG) found that Tufts Health Plan Inc. (Tufts) received at least $3.7 million of net overpayments from 2015 to 2016 for incorrectly submitting selected high-risk diagnosis codes.
Physician documentation of heart failure must specify the type and severity of the illness to apply the most accurate code. Alba Kuqi, MD, MSHIM, CDIP, CCS, CCDS, CRCR, CICA, CSMC, RHIA, CCM , breaks down clinical documentation and ICD-10-CM coding for four types of heart failure.
The primary purpose of CDI work is to review medical records to increase the accuracy and specificity of provider documentation. Review the primary responsibilities of a CDI specialist including documentation review, querying, and physician education.
CDI specialists must be able to apply both clinical and coding knowledge in order to discern relevant clinical conditions, and they must be able to analyze the quality of provider documentation and identify any gaps or inconsistencies in information between the health record and the associated data.
