Every Code Counts

The Code Hard Truth.

In reviewing a patient’s record, even the smallest detail can have significant impacts. Here at HIA, we clear the air with unparalleled skills to know exactly what to look for when it comes to identifying proper code assignments.

Click on each object to learn how HIA got this one right.

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The Code Hard Truth.

In reviewing a patient’s record, even the smallest detail can have significant impacts. Here at HIA, we clear the air with unparalleled skills to know exactly what to look for when it comes to identifying proper code assignments.

Swipe to learn how HIA got this one right.

Z79.1 Long term use of nsaids

The documentation indicated long term use of NSAIDS resulting in the need for a gastrectomy

Stomach ulcers can occur with long term use of NSAIDS. Diagnosis and treatment will depend on symptoms and the severity of the patient’s ulcer.

K25.1 ACUTE GASTRIC ULCER WITH PERFORATION

After a lengthy partial gastrectomy the patient is put on a mechanical ventilator as standard ICU post op.

The patient is weaned and extubated by postop day three without any problems.

J95.821 Acute postprocedural respiratory failure

The physician monitoring the patient in the ICU documents 'Postoperative Respiratory Failure’ in the record. The patient is weaned and extubated by postop day three without any problems.

HIA recommends a query to the physician or referral to a physician liaison. There are no supporting clinical indicators that the patient went into acute respiratory failure postoperatively.

PSI 11 Quality measures

The original coder assigned J95.821, "Acute Postprocedural Respiratory Failure" with POA of "No" as a secondary diagnosis. This case now meets Patient Safety Indicator 11 (PSI 11) as defined by the Agency of Healthcare Research and Quality (AHRQ).

After HIA’s review, the postoperative acute respiratory failure code is not assigned, PSI 11 is no longer applicable and the hospital avoids negative quality measurement data statistics for this case.

$$$ Financial impact

If J95.821 was coded incorrectly, the case now meets PSI 11. PSI information is collected by CMS and other payers for future reimbursement via the Value Based Purchasing system. Hospitals that report excessive postoperative complications can see their reimbursements affected due to poor quality of patient care.

Thanks to HIA’s advice, the postoperative acute respiratory failure code is revised, PSI 11 is no longer applicable and the hospital avoids potential adverse reimbursement impacts.

Picture yourself at HIA

Picture yourself part of a close-knit work family that prides itself on inclusiveness and elite services. In addition to a generous benefits package that includes an excellent starting salary and many company perks, you will be supported with a knowledgeable Education and Quality Assurance Department to keep you ahead of the curve. With an extensive library of action plans designed to target and improve your coding skills, you will always be challenged and continue to grow.

View our current opportunities and apply today at hiacode.com/careers.

1 out of 3 records reviewed by HIA identified coding and/or documentation discrepancies with opportunities for education

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