Q: Our physicians document a diagnosis of pneumonia but do not normally make a specific connection with the patient's ventilator status, even when this is obvious from the record. For example, the patient's been on the ventilator support immediately prior to the diagnosis. Can I report this as ventilator-associated pneumonia in ICD-10-CM without the documentation specifically connecting the conditions?
On the surface, you may think that transitioning from ICD-9-CM to ICD-10-CM for reporting schizophrenia, schizoid personality, and bipolar disorders is a dramatic change. However, Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, reveals that with some minor adjustments, the change can be a smooth one.
ICD-10-CM includes more specificity than ICD-9-CM, but it still includes unspecified codes. Adele Towers, MD, MPH, Joanne Schade-Boyce, BSDH, MS, CPC, ACS, PCS, Michael Gallagher, MD, MBA, MPH, Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC , and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, explain when reporting an unspecified ICD-10-CM code is a good option.
CMS posted updated versions of all the guidance documents posted on the Inpatient Hospital Review site. The agency also posted a new document reviewing the status of the probe and educate audits, including examples of some of the errors the MACs have found in audits thus far.
Some of the most significant changes in cardiovascular coding in ICD-10-CM involve coding for myocardial infarctions (MI). Laura Legg, RHIT, CCS , and Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, review new guidelines and specificity involved in ICD-10-CM MI coding.
ICD-10-CM provides many more combination codes for drug- and alcohol-related diagnoses than ICD-9-CM. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, explains how this could actually result in less work for coders.
Coders may struggle to differentiate between ICD-10-PCS root operations Excision and Resection. Nena Scott, MSEd, RHIA, CCS, CCS-P, AHIMA-approved ICD-10-CM/PCS trainer, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, illustrate the details that will help coders arrive at the correct root operation.
Coders and clinicians seem to speak different languages. CDI specialists often serve as the translators between clinicians and coders, so it's important that all three groups work together. Cheryl Ericson, RN, MS, CCDS, CDIP , AHIMA-approved ICD-10-CM/PCS trainer, Darice M. Grzybowski, MA, RHIA, FAHIMA , Jonathan Elion, MD, Kathy DeVault, RHIA, CCS, CCS-P , and William E. Haik, MD, FCCP, CDIP , offer tips for determining when to query.
Coders may struggle to differentiate the ICD-10-PCS root operations excision and resection. Nena Scott, MSEd, RHIA, CCS, CCS-P, AHIMA-approved ICD-10-CM/PCS trainer, and Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, explain why excision is the root operation of choice for excisional debridement and sebaceous cyst removal.
James S. Kennedy, MD, CCS, discusses the increased clinical specificity required for coders to report strokes and transient ischemic attacks in ICD-10.
When it comes to coding malnutrition, coders need to see very specific information in the physician documentation. James S. Kennedy, MD, CCS, William E. Haik, MD, FCCP, CDIP , and Mindy Hamilton, RD, LD, review the clinical factors for malnutrition and how to assign the correct ICD-9-CM codes.
CMS will conduct full end-to-end testing—from submission to remittance advice—with a select sample of providers in July. CMS first announced the decision in MLN Matters® SE1409 and provided additional details during the February 20 webcast, CMS ICD-10 Readiness.
Coders may need to have a conversation with physicians about how changes in ICD-10-CM could require additional documentation for mental disorders due to a known physiological condition. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I , AHIMA-approved ICD-10-CM/PCS trainer, compares coding for these conditions in ICD-9-CM and ICD-10-CM.
Heather Taillon, RHIA, Cheryl Collins, BS, RN , and Andrea Clark, RHIA, CCS, CPC-H , explain the basic rules regarding principal diagnosis selection in general and for neoplasms in particular in ICD-9-CM.
The World Health Organization (WHO) is delaying the launch of ICD-11 until 2017. The WHO did not formally announce a delay, but its website now lists ICD-11 as due by 2017.
