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Part 4: Sepsis Series | Are Clinical Indicators Present to Support the Diagnosis of Sepsis?
In Parts 1, 2 and 3 we learned about what sepsis is, sequencing of sepsis and what documentation is needed to report severe sepsis. In Part 4, we will look at clinical indicators needed to clinically support the diagnosis of sepsis and determine if a query is indicated.
Part 3: Sepsis Series | Severe Sepsis Documentation and Reporting
Severe sepsis occurs when sepsis progresses and signs of organ dysfunction/failure develop. One site stated that approximately 30% of patients with severe sepsis do not survive. Patients may develop one organ dysfunction/failure, multi-system organ failure and/or septic shock.
Part 2: Sepsis Series | Sequencing the Diagnosis of Sepsis
In Part 2 of our Sepsis Series, we are going to focus on sequencing of sepsis when the diagnosis is clearly documented. Later in the series we will look at what to do when the diagnosis is not clearly documented.
Part 1: Sepsis Series | What is Sepsis?
In this series, we will learn what sepsis is or causes of sepsis, how to sequence the diagnosis in ICD-10-CM, what are the clinical indicators for sepsis, is a query necessary before reporting the diagnosis of sepsis, and how to prevent denials on sepsis records.
Part 4: New ICD-10 Codes and IPPS Changes
In the previous three parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2020 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2020.
Part 3: New ICD-10 Codes and IPPS Changes
In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes. In this session we will review the major IPPS changes for FY2020. On August 2, 2019, CMS published the Final Rule for IPPS (CMS-1716) FY2020 IPPS Final Rule.
Part 2: New ICD-10 Codes and IPPS Changes
In Part 1 of this 4 part series we discussed some of the new ICD-10-CM diagnosis changes. In Part 2 we present the significant ICD-10-PCS procedure code changes. There are 72,184 total ICD-10-CM codes for FY2020.
Part 1: New ICD-10 Codes and IPPS Changes
This is Part 1 of a 4 part series on the FY2020 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. There are 72,184 total ICD-10-CM codes for FY2020.
Part 14: Spinal Fusion Coding — Spinal Fusion Series Summary
We have finished with the step-by-step coding tidbits on coding of spinal fusions. If you were not able to catch Parts 1-13 of this series focused on spinal fusions, please visit hiacode.com/topics/series/spinal-fusion-coding/.
Part 13: Spinal Fusion Coding — Harvesting of Autograft for Spinal Fusion
In Part 12, we focused on intra-operative peripheral neuro monitoring used during spinal fusion surgery. In Part 13, we are going to focus on harvesting of autograft and is it coded. Remember in Part 6, we learned that autograft is bone from the patient.
Part 12: Spinal Fusion Coding — Intra-Operative Peripheral Neuro Monitoring
In Part 11, we focused on identifying the computer assisted navigation used during spinal fusion surgery. In Part 12, we are going to focus on intra-operative peripheral neuro monitoring.
Part 11: Spinal Fusion Coding — Computer Assisted Navigation
In Part 10, we focused on identifying whether or not hardware from a previous spinal fusion is coded. In Part 11, we are going to discuss computer assisted navigation.
Part 10: Spinal Fusion Coding — Removing Hardware from Previous Fusion
In Part 9, we focused on identifying if decompression was also performed and if so, on which body part. In Part 10, we are going to focus on identifying if hardware was removed from a previous fusion site.
Part 9: Spinal Fusion Coding — Was A Decompression Done During Spinal Fusion?
In Part 8, we focused on identifying if a discectomy was performed, and if so, if it was a partial or a total discectomy. In Part 9, we are going to focus on identifying if a decompression was performed, and if so, was it of the spinal cord, spinal nerves or both?
Part 8: Spinal Fusion Coding — Discectomy During Spinal Fusion
In Part 7, we focused on identifying any instrumentation that may be used during a spinal fusion. In Part 8, we are going to focus on identifying if a discectomy is performed and if this is an excision or a resection of the disc.
Part 7: Spinal Fusion Coding — Identify Any Instrumentation or Device Used
In Part 6, we focused on identifying the type of bone graft product used for the spinal fusion. In Part 7, we are going to focus on identifying any instrumentation or device used.
Part 6: Spinal Fusion Coding — Identify the Type of Bone Graft Used for Fusion
In Part 5, we focused on identifying the approach being used for the spinal fusion. In Part 6, we are going to focus on identifying the type of bone graft used for the spinal fusion.
Part 5: Spinal Fusion Coding — Identifying the Approach Being Used for Fusion
In Part 4, we focused on determining the spinal column being fused. In Part 5, we are going to focus on identifying what approach is being used to complete the spinal fusion (anterior, posterior or both).
HIA Launches Buddy Up Program for New Hires
This past year, HIA implemented “Buddy Up,” a program designed to help the new hire have a smooth transition into their new HIA roles with the assistance of a “buddy.” What is a Buddy? The Buddy is simply a peer who can guide the new hire in order to make them feel more comfortable. We are very proud of this program and have many success stories that we would like to share. Take a look at the wonderful feedback we have received below.
Part 4: Spinal Fusion Coding — Identifying the Column Being Fused
In Part 3, we focused on determining the level of the fusion(s) and how to determine the number of vertebrae fused. In Part 4, we are going to focus on identifying which column is being fused (anterior, posterior or both).
Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
In Part 1, we learned the diagnoses associated with the need for spinal fusions, and in Part 2 the need to identify if the fusion is an initial or refusion of the vertebrae. In Part 3, we are going to focus on determining the level(s) of fusion, as well as the number of vertebrae fused.
Part 2: Spinal Fusion Coding — Initial Fusion or Refusion
In Part 2, we are going to look at the differences between initial fusion and a refusion. In ICD-9, there were specific codes to show if the fusion was an initial fusion, or if it was a refusion. In ICD-10-PCS, initial fusions and refusion procedures are coded to the same root operation “fusion.”
Part 1: Spinal Fusion Coding — Diagnoses Responsible
This is Part 1 of a 14 part series focusing on education for spinal fusions. Spinal fusion coding is a tough job for coders. There are so many diseases/disorders that result in the need for spinal fusion, and even more choices in reporting the ICD-10-PCS codes.
Query Tip: Writing a Query Question – Simple and Concise is the Key
The question asked in a physician query may be the most important element of the document. Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking.
Coding Tip: Coding Complications of Transplanted Organs
Coding complications of transplanted organs has always been a coding dilemma. With the implementation of ICD-10-CM that didn’t change. However, coders have multiple directives to help in determining what a complication of the transplant is vs. non-transplant conditions and diseases.
Find Your Routine: Take Advantage of Educational Opportunities
We interviewed our most productive coders, reviewers and members of our education team, asking them what steps they take to find a rhythm that works for them. This week, we talked with Beth Martilik, MA, RHIA, CDIP, CCS, Assistant Director of Education, about the steps she takes to find her routine.
Coding Tip: Atrial Fibrillation
With the implementation of ICD-10-CM came more codes for reporting many different conditions and diseases, and atrial fibrillation is one of those. For many years there was only one code available for reporting this condition, even when the physician further specified the type of atrial fibrillation that the patient had. In ICD-10-CM, there are four codes to report atrial fibrillation.
Coder Q&A with Pat Macc: Mucoid Casts and Mucus Plugs
We have a case where the physician removes mucoid casts found during bronchoscopy. We have also seen mucus plugs removed during bronchoscopy. The MD performs bronchial washings then removes a large amount of tenacious and thick mucoid casts via bronchoscopy. Is this coded drainage, extirpation or excision? What body part is used?
Query Tip: How to Be More Efficient
The key to making the query process more efficient is to look for words or documentation while reviewing the record that may signal a potential query opportunity and to note the finding at that time. By the time a coder reaches the end of a record, documentation may have been found to eliminate the need for the query.
DISCOVER THE DIFFERENCE BETWEEN
THE ROUTINE AND THE UNEXPECTED.
When it comes to coding and documentation, finding your own rhythm can lead to positive results. That’s why we take every step into consideration when telling each patient’s story and help guide you along the way.
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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