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Query Tip: Be Careful Using Yes/No Query Format
Queries in a Yes/No format are limited to use in the four specific circumstances. This format may not be used when only clinical indicators of a condition are present, but the diagnosis has not been documented in the health record.
Query Tip: The Many Meanings of “Unable to Determine”
Queries written in a multiple-choice format include a short list of options for physician response. These options must be relevant and supported by the clinical indicators included in the query. In the event a physician cannot provide further specificity by using one of these listed options, there must be an additional option for “unable to determine.”
Coding Tip: Getting Control of Root Operation Control
Since the implementation of ICD-10-PCS in 2015, yearly changes have been made regarding the definition of, and guidelines associated with, the root operation Control. This has caused coding professionals much confusion in determining whether to assign a procedure to root operation Control, to assign another root operation, or to not assign a procedure code at all. The objective of this article is to learn when the root operation Control should be assigned when coding a procedure.
IPPS Final Rule: Here’s What You Need to Know
The policies in the IPPS/LTCH PPS final rule further advance the agency’s priority of creating a patient-centered healthcare system by achieving greater price transparency, interoperability, and significant burden reduction so that hospitals can operate with better…
Coding & Quality Measures: The Code Hard Truth
In this current, ever-changing healthcare climate, health systems face many challenges. Facilities large and small must be dedicated to improving documentation and reducing complications, HACs, infection rates, and readmissions as they endeavor towards value-based care. Coding inaccuracies can really undermine…
Achieve Sustained Results with HIA’s Coding Services
It’s imperative, in today’s challenging healthcare environment, that organizations demand complete and accurate coding practices from their vendors if they want: Appropriate and timely reimbursement; Representative quality measures; Improved CMI; Reduction in payor denials and; Mitigation of compliance risks.
Query Tip: Is Sepsis Present on Admission?
In addition to positive clinical indicators documented at the time of admission, any of these that occur within the few days after admission should also be included. This will support the fact that sepsis could have developed after admission. It is important that a POA query give equal attention to what supports POA yes, as well as POA no to avoid the appearance of a leading query.
CMS Releases Proposed Physician Fee Schedule Rule for CY 2019
This major proposed rule addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute.
Want a sneak peek at ICD-11?
For example, open the ICD-11 online link and click on “Browse the release version.” Then choose “Coding Tool” tab at the top. We chose “sepsis.” Sepsis without shock is coded to 1G40. Sepsis with septic shock is coded 1G41. A bit different than ICD-10!
Coding & Quality Measures Tip PQI 07: Hypertension Admission Rate
Did you know that by coding hypertension with associated CKD correctly along with any surgical dialysis access creation on patients admitted with hypertension, will keep the case out of the AHRQ PQI #07: Hypertension Admission Rate quality measure?
ICD-11: 3 Key Takeaways
On June 18, 2018, the World Health Organization (WHO) released a preview of its new International Classification of Diseases (ICD-11). ICD-11 will be formally presented at the World Health Assembly on May 2019 for adoption by Member States, and will come into effect the 1st of January 2022. The advanced preview will allow countries to plan how to use the new version to prepare translations and train health professionals.
Coding Tip: Reporting Intra-Aortic Balloon Pump (IABP) in ICD-10-PCS
From a coding perspective, the IABP is not classified as a device such as the VAD’s. The IABP is not coded as a device within ICD-10-PCS and is coded with the root operation of “Assistance.” The ICD-10-PCS code for insertion of an IABP for continuous pumping would be 5A02210, Extracorporeal or Systemic Assistance, Physiologic Systems, Assistance, Cardiac, Continuous, Output, Balloon Pump.
Query Tip: Query Question is Key
The key to a quality physician query is the question. The question provides direction for the choice of clinical indicators and options for response. So why do so many coders have trouble writing the question? My theory is that coders overthink the question rather than keeping it simple and to the point. The best way to get a physician to answer a query is with a question that makes sense and eliminates guessing as to what is being asked.
Q1 2018: Top 5 Procedure Code Changes
Locating ventilator times were difficult in the paper medical record, but has not become any easier with the implementation on the electronic health record (EHR.) Coders should be encouraged to review the record for exact ventilator times. As mentioned above, this could come down to minutes when selecting the correct ICD-10-PCS code.
Who Tells Your Story?
Hamilton. If you haven’t seen it, you’ve heard of it. The Broadway mega-hit has been the toughest ticket on Broadway since its debut in 2015. For the uninitiated, Hamilton explores the life and triumphs of the previously obscure “ten-dollar founding father,” Alexander Hamilton, through rap, hip-hop, and musical theatre.
Coding Tip: Excisional Debridement Coding to the Furthest Layer
Procedure code assignment for excisional debridement has always been a focus area in coding audits. The biggest concern is whether or not the debridement is truly excisional in nature, and if the documentation truly supports an excisional debridement. HIA has written a previous Coding Tip on determining nonexcisional vs excisional debridement.
Query Tip: Bullet vs Paragraph: What Format is Best for Clinical Indicators?
Beth Martilik, MA, RHIA, CDIP, CCS Assistant Director of Education AHIMA Approved ICD‑10 Trainer and Ambassador The ultimate goal of a physician query is to obtain clarity to physician documentation in the patient’s health record. In order to accomplish this goal,...
Coding Tip: New Technology Drugs FY 2018
Kim Carrier RHIT, CDIP, CCS, CCS-P Director of Coding Quality Assurance AHIMA Approved ICD-10-CM/PCS Trainer New Technology-ICD-10-PCS Section “X” DRUGS Section “X” is a separate place within ICD-10-PCS for certain new technology procedures (such as new technology...
Query Tip: Avoiding a Leading Query – Introduction of a New Diagnosis
Beth Martilik, MA, RHIA, CDIP, CCS Assistant Director of Education AHIMA Approved ICD‑10 Trainer and Ambassador “A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or...
Coding Tip: Aromatase Inhibitor Use Reporting
Kim Carrier RHIT, CDIP, CCS, CCS-P Director of Coding Quality Assurance AHIMA Approved ICD-10-CM/PCS Trainer With the implementation of ICD-10-CM came more codes for reporting the long-term use of drugs. There is now a code to report long-term use (LTU) of aromatase...
Coding Tip: Bronchoscopy with Removal of Mucus Plugs or Foreign Body
Pat Maccariella‑Hafey, RHIA, CDIP, CCS, CCS‑P, CIRCC Executive Director Of Education AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador Bronchoscopy with Removal of Mucus Plugs or Foreign Body HIA has previously discussed the coding of bronchoscopy with...
Query Tip: The Importance of Queries
Most queries are written to clarify documentation as it relates to reimbursement. However, code assignment not only impacts reimbursement, but also other significant uses of coded data. Ideally, queries would be written as necessary to ensure data integrity and full and complete documentation.
Coding Tip: Inpatient Coding of Probable Diagnoses
The rules about coding probable, possible and questionable diagnoses did not change with the implementation of ICD-10-CM. A possible, probable, suspected, likely, questionable, or still to be ruled out condition can be coded if still documented as such at the time of discharge.
CMS Changes the Rules on Student Documentation
Anyone who has coded or reviewed documentation in a teaching facility is familiar with the Medicare Claims Processing Manual, Chapter 12, Section 100.1.1. This section of the manual contains the guidelines for teaching physicians.
Coding Tip: Chronic Kidney Disease Coding
Kim Carrier RHIT, CDIP, CCS, CCS-P Director of Coding Quality Assurance AHIMA Approved ICD-10-CM/PCS Trainer Chronic kidney disease (CKD) is the gradual loss of kidney function. The function of your kidney is to filter waste and excess fluids from your blood and...
Coding Tip: Coding Changes for Pulmonary Hypertension in FY2018
For FY2018, coding for pulmonary hypertension has changed. There are new codes and expanded codes for the Subcategory I27.2.
Ask Yourself These 3 Questions Before Your Next Coding Review
So, you know you need a coding review – where do you start? Defining your goal should always be step one, but that’s not always cut and dry. The answer varies based on the objectives of your review.
Coding Tip: Reporting Diabetic Ketoacidosis (DKA)
For FY2018 there is a new code to report Type 2 diabetic ketoacidosis (DKA). This was previously reported with code E13.1-, other specified diabetes mellitus with ketoacidosis with or without coma. Now, there is a code specifically for reporting this diagnosis. E11.1- is used to report Type 2 diabetes with DKA with or without coma.
Coding Tip: PCS Coding Control vs. More Definitive Root Operation
There were changes made, yet again, to the definition of the root operation “Control”. Per the ICD-10-PCS Official Guidelines for Coding and Reporting 2018, “The root operation Control is defined as, “Stopping, or attempting to stop, postprocedural or other acute bleeding.”
We understand the challenges
Critical Access Hospitals face.
Rarely does a CAH have the luxury of a dedicated coding manager, much less an educator and internal auditor. HIA’s service is aimed at providing a reliable resource to address all 3 important functions and more – all for one fixed annual fee.
We understand the challenges
Critical Access Hospitals face.
Rarely does a CAH have the luxury of a dedicated coding manager, much less an educator and internal auditor. HIA’s service is aimed at providing a reliable resource to address all 3 important functions and more – all for one fixed annual fee.
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