MS-DRG audits are nothing new, but their frequency has significantly increased over the last two years. In this article, Sam Antonios, MD, FACP, FHM, CPE, CCDS , gives facilities tips to increase the likelihood of overturning MS-DRG denials.
Erica E. Remer, MD, FACEP, CCDS, writes about how using unspecified diagnoses in the inpatient world results in deflated quality metrics. Remer helps clinical documentation specialists remedy the situation and gives advices on how to aid providers in documenting to the level of specificity that is now needed.
Shannon Newell, RHIA, CCS, discusses a refined version of the Patient Safety Indicator (PSI) 90 composite by the Agency for Healthcare Research and Quality, and how it has a significant impact on what discharges are included in PSI 15. Note: To access this free article, make sure you first register for the free content if you do not have a paid subscription.
Providers are still working to understand the impact of the February release of the controversial third international consensus definitions for sepsis and septic shock. James S. Kennedy, MD, CCS, CDIP , tackles this new sepsis definition in part two of his two-part series.
This article is part two of a two-part series on the definition changes for sepsis. Reread part one in the October issue of BCCS. In my October Clinically Speaking column, we discussed the evolution of the definition of sepsis and its implications in clinical care (Sepsis-1, Sepsis-2, and Sepsis-3), quality measurement (CMS' SEP-1 core measure), and ICD-10-CM coding compliance.
The recent adoption of a refined version of the Patient Safety Indicator (PSI) 90 composite by the Agency forHealthcare Research and Quality (AHRQ) has a significant impact on what discharges are included in PSI 15 (Unrecognized Abdominopelvic Accidental Puncture Laceration Rate).
The new guideline for code assignment and clinical criteria in the 2017 ICD-10-CM Official Guidelines for Coding and Reporting does not mean clinical documentation improvement is going away; instead it just upped the ante for continued improvement.
As if coders and clinical documentation improvement specialists aren't under enough pressure as it is, the advent of the 2017 Official Guidelines for Coding and Reporting brings to the table new documentation requirements for pressure ulcer coding. The guidelines can be viewed here: www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf .
Trey La Charité, MD , writes about how he feels the days of merely maintaining compliance with published coding guidelines are gone, and suggests ways to protect a facility and appeal audits.
This October celebrates the eight month anniversary of the February release of the controversial third international consensus definitions for sepsis and septic shock. James S. Kennedy, MD, CCS, CDIP , tackles this new sepsis definition in part one of his two-part series.
With all the hoopla over sepsis, pressure ulcers, and diabetes coding, there’s a little gem of coding advice that has been overlooked since ICD-10 was released: pneumonia and chronic obstructive pulmonary disease. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , writes about these changes and helps to decipher the new guideline changes. Note: To access this free article, make sure you first register for the free content if you do not have a paid subscription.
Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, discusses the new documentation requirements for pressure ulcer coding in the 2017 Official Guidelines for Coding and Reporting. Note: To access this free article, make sure you first register for the free content if you do not have a paid subscription.
Shannon Newell, RHIA, CCS, writes about how certain hospitals will be required to participate in the Comprehensive Joint Replacement Model and a new orthopedic payment model called SHFFT if an August 2 proposed rule is finalized.
Since the physician doesn't need to document a specific root operation, coders cannot rely solely on the terms the physician uses; thus it is important for each coder to fully understand each definition, including the root operations that put in, put back, or move some or all of a body part.
In our computer-savvy tech world, the medical field has been notoriously slow to respond to newer technologies and applications of computer-assisted enhancements. However, in the HIM market, computer-assisted coding (CAC) has been touted to boost coding accuracy and productivity, in addition to being an important tool for the remote inpatient coder.
Resiliency is the ability to spring back or rebound. In sports, it's one of the mental attributes a player must have. Coders are resilient: bouncing back from one change after another, deciding to code smarter and faster, and having the patience to do whatever is expected?even amid closing grace periods and guideline controversies.
If your hospital resides in one of the 67 metropolitan statistical areas (MSA) required to participate in the Comprehensive Joint Replacement Model (CJR), you will also be required to participate in a new orthopedic payment model called SHFFT (surgical hip and femur fracture treatment) if an August 2 proposed rule is finalized.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, continues her review of the updated 2017 ICD-10-CM guidelines by explaining how changes to sections for laterality and non-provider documentation will impact coders and physicians. 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.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, delves into chapter-specific guidance included in the updated 2017 ICD-10-CM guidelines, including changes for diabetes, hypertension, pressure ulcers, and more.
Laurie L. Prescott, MSN, RN, CCDS, CDIP , writes that as many CDI teams work to expand their risk adjustment programs, a melding of two skill sets, that of CDI specialists and coding professionals, are required to succeed.
Since the physician doesn't need to document a specific root operation, coders cannot rely solely on the terms the physician uses; thus it is important for each coder to fully understand each root operation, including Restriction and Occlusion. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Laura Legg, RHIT, CCS, CDIP , explains how the coming months will prove to be challenging for coders because of the new ICD-10 codes for both diagnoses and procedures beginning October 1. Along with that, we’ll see the end of the CMS grace period on code specificity for Part B physician payments and updated ICD-10-CM Official Coding Guidelines .
Sharme Brodie, RN, CCDS , discusses how to decipher between some potentially confusing—and possibly conflicting—information regarding diabetes documentation requirements.
Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer, writes that the majority of the 2017 IPPS final rule updates are consistent with those outlined in the proposed rule, but contain a few refinements. She reviews refinements to the number of claims-based outcomes linked to payment.
CMS released a national coverage determination recently covering a percutaneous left atrial appendage closure through their “coverage with evidence development” policy. CMS says this policy will be fully implemented on October 3, 2016.
Accurately reporting altered mental status and encephalopathy can be a challenge that requires coordination between coders and providers. James S. Kennedy, MD, CCS, CDIP, explains best practices for coding these tricky conditions. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Q: The coders at my facility have started automatically linking congestive heart failure, hypertension, and chronic kidney disease (CKD) to the combination code without any documentation of CHF “due to” hypertension. There is no documentation of hypertensive heart disease anywhere in the record, and the diagnoses are not linked anywhere in the record.
Last month, I wrote about the role of coding and CDI compliance in ensuring the clinical validity of submitted ICD-10-CM/PCS codes, which impact payment, outcomes measurement (e.g., complications, mortality, and readmissions), and patient safety.
The fiscal year (FY) 2017 IPPS final rule was released August 2 and will be published in the Federal Register August 22. The majority of the finalized updates are consistent with those outlined in the proposed rule, but with a few refinements to applicable time periods. The final rule expands and refines the number of claims-based outcomes linked to payment under these programs. Let's review a few of the key changes to support your CDI program's strategic focus for the coming year.
CMS released the fiscal year (FY) 2017 IPPS final rule August 2, and ICD-10-CM/PCS code changes and the addition of the Medicare Outpatient Observation Notice (MOON) both had starring roles. CMS also made changes to several quality initiatives and reversed the agency's 0.2% payment reduction instituted along with the 2-midnight rule first implemented in the FY 2014 rule.
Richard D. Pinson, MD, FACP, CCS , discusses the new Sepsis-3 definition and how the classification has been the subject of great controversy and consternation since its publication in The Journal of the American Medical Association.
Robert Stein, MD, CCDS, and Shannon Newell, RHIA, CCS, co-author this article that provides insights into how clinical documentation and reported codes may impact payments and offer guidance on some common CDI challenges to strengthening data quality. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP , writes about how computer-assisted coding software can be used to boost coding accuracy and productivity, in addition to being an important tool for the remote coder.
Shannon Newell, RHIA, CCS, writes about recently proposed modifications to Patient Safety Indicator 90, and how a fact sheet released by the measure's owner, the Agency for Healthcare Research and Quality, provides insights into what changes may lie ahead.
James Kennedy, MD, CCS, CDIP , offers his take on AHIMA’s recently published clinical validation practice brief. Given that AHIMA is one of the ICD-10 Cooperating Parties, their practice briefs must be read closely, and if agreeable, incorporated into one’s compliance plan. Note: To access this free article, make sure you first register if you do not have a paid subscription.
We as coders, clinical documentation specialists, and compliance officers, are actively invested in coding compliance, aren't we? AHIMA and ACDIS emphasize coding compliance in their codes of ethics. If we aren't interested in coding compliance, why are we reading newsletters named Briefings in Coding Compliance Strategies and other similar publications?
"You are your own best teacher," or so the old adage goes. Sure, goodies and gifts are great for recognizing high-quality documentation, but for CDI teams struggling to obtain physician buy-in, the best strategy may be found in their providers' own records.
The accurate capture of acute respiratory failure has been a long-standing challenge for CDI programs. The accurate reporting of this condition as a post-procedural event can be even more difficult.
Since the physician doesn't need to use a specific root operation term in documentation, coders should not rely solely on the term the physician uses. Coders need to know the definitions and the nuances of the root operations, especially those involving a device.
Laurie L. Prescott, MSN, RN, CCDS, CDIP, provides coders with tips on coding heart failure, obstetrics, and linking language, and also offers the latest guidance given by AHA Coding Clinic for ICD-10-CM/PCS ® on these topics.
Paul Evans, RHIA, CCS, CCS-P, CCDS, give coders ICD-10-PCS documentation and coding tips for three of the most common, and commonly misunderstood, procedures performed via bronchoscopy.
Since the physician doesn't need to document a specific root operation, coders cannot rely solely on the terms the physician uses; thus it is important for each coder to fully understand each root operation, especially Control and Repair. Note: To access this free article, make sure you first register if you do not have a paid subscription.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, address the inpatient side of bariatric surgery, and how obesity and body mass index play a role in coding.
The last few weeks have brought us some direction, though, including the release of approximately 1,900 new ICD-10-CM codes for 2017. (The list can be found on CMS' website.) We also have a list of approximately 3,600 new ICD-10-PCS codes for 2017. (This is also available on CMS' site.) Of course, we will also be looking for changes in DRG mappings and the CC/MCC lists, which will likely appear later this summer.
