Query Tip: Query for Pathology Results
Tissue findings interpreted by a pathologist are not equivalent to the attending physician’s medical diagnosis based on the patient’s clinical condition. If the attending physician has not indicated the significance of an abnormal finding within a pathology report, the coder must query to determine if the finding may be reported.
Coding guideline III.B. states:
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added. Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider.
One pathological finding that may have implications on DRG assignment is metastasis. The attending physician may document a diagnosis of primary malignancy within the record, but fails to indicate the presence of any metastatic sites. If a pathological finding of metastasis was found in the sample, a query should be generated to confirm the clinical significance of this finding. A sample query is found below.
*Right colon and ileum with findings of adenocarcinoma extending through the muscularis propria into the surrounding pericolic soft tissue – Thirteen of thirty-three lymph nodes positive (Pathology Report)
*No documentation elsewhere in record regarding metastatic sites
Can you confirm any metastatic sites based on the pathology results?
In this example, there is no evidence in the pathology report of more than one possible metastatic site. If the coder listed options for response (i.e. – abdominal lymph nodes, other site, unable to determine), the query would be considered leading. Options should only be listed if more than one specific site can be supported by the pathology report documentation.
The information contained in this query advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
In HIA quality reviews we are finding that some coders are reporting Z41.2—Encounter for routine and ritual circumcision, during the male newborn birth admission, when circumcision is performed prior to discharge.
The cause/etiology of GI bleeding is not always easily determined. During procedures, to work the bleeding up, there are often multiple potential sources of bleeding found but not identified as the culprit. Many of these findings have “with” or “in” in the main or subterms.
On December 1, 2018, the HIA team based at our headquarters in Pawleys Island, South Carolina received a visit from a surprise guest – meet Otis, HIA’s very own Elf on a Shelf. Otis will be sticking around until Christmas to keep an eye on all of us. We have a feeling he may get into some trouble! Check back daily to see what Otis is up to. #OtisOnOtisDrive
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our new series, Find Your Routine, we interviewed our most productive coders and asked them what steps they take to find a rhythm that works for them. This week, we talked with Crystal Junkins, CCS, CPC, Coding Specialist with Health Information Associates, about the steps she takes to find her routine.
COPD is a respiratory condition where there is chronic obstruction to airflow in the lungs. Air is breathed into the lungs but a patient with COPD has trouble emptying air out of the lungs. This can also cause patients with COPD to have CO2 retention. COPD is an irreversible and progressive disease in which the lung function worsens as time goes on.
It’s that time of the year where HIM professionals take a peek at what changes are coming for CPT in the new year, 2019. Did you know that CPT started in 1966 with about 3,500 codes? For 2019, there are a total of 10,294 CPT codes.
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our new series, Find Your Routine, we interviewed our most productive coders and asked them what steps they take to find a rhythm that works for them. This week, we talked with Amy Pang, RHIA, CCS, Coding Specialist with Health Information Associates, about the steps she takes to find her routine.
For FY 2019, ICD-10-CM has added a new code for reporting of lacunar cerebral infarction. This is good news for coders since we see this specific type of cerebral infarction documented often. The new code that is reported for lacunar infarction is I63.81 —Other cerebral infarction due to occlusion or stenosis of small artery.
In 2003, the Centers for Medicare and Medicaid Services (CMS) implemented Risk Adjustment Factors (RAF) and Hierarchical Condition Category (HCC) coding to identify individuals with serious and/or chronic illnesses and assign them a risk factor score that is based on a combination of demographic information and reported diagnoses.
The ICD-10-CM/PCS code changes – effective October 1, 2018 to September 31, 2019 – could be the culprit. Comparatively speaking, there are far less changes this year than in years past. The release includes: 279 new codes, 51 deleted codes,143 revised codes. But don’t let the smaller amount of changes fool you…
With the publication of the new ICD-10-CM Official Guidelines for Coding and Reporting for FY 2019, we finally have an answer regarding reporting of BMI in pregnancy. The new guideline does state “do not assign BMI codes during pregnancy.”
Conflicting documentation occurs when health care providers call the same condition different things. When none of the documented conditions are clearly ruled out by the physician, coders may find it necessary to query for the most appropriate diagnosis.
In reviewing hundreds of contracts, the OIG found that insurers overturned 75% of their own denials upon appeal—approximately 216,000 denials each year. However, while the odds of winning an appeal are seemingly good, many providers simply don’t have the time or the internal staff and infrastructure needed to engage in the process.
When coding a record with documented bullying, this is coded as child or adult psychological abuse (initial/subsequent encounter or sequela) either as confirmed or suspected. The encounter and whether this is confirmed or suspected is needed in order to assign the appropriate diagnosis code.
It’s Halloween season! It’s time to overindulge on candy, fight over the best costume, become irrationally scared of things like the number 13, and have nightmares of your 6th birthday with that terrifying clown. As for us, we’re getting in the spirit with 13 spooky ICD- 10 codes! Beware – it’s scary out there.
Section “X” is a separate place within ICD-10-PCS for certain new technology procedures (such as new technology drugs). Section “X” does not introduce any new coding concepts or unusual guidelines for correct coding and maintains continuity with the other sections in ICD-10-PCS.
Coding Tip: New ICD-10-CM General Coding Guideline — Coding for Healthcare Encounters in Hurricane Aftermath
With the Hurricane season in full swing, this new guideline will be helpful in reporting the external cause codes when an injury occurs as a result of the hurricane, and also help in determining sequencing of the reported codes.
The refined Stroke 30-day mortality measure (MORT-30-STK) is a statistic defined as death occurring within 30 days of a diagnosed stroke. The Centers for Medicare & Medicaid Services (CMS) publicly reports a 30-day hospital-level stroke mortality measure on Hospital Compare as part of the Inpatient Quality Reporting (IQR) program.
“Lobar” pneumonia references a form of pneumonia that affects a specific lobe or lobes of the lung. This is a bacterial pneumonia and is most commonly community acquired. Antibiotics are almost always necessary to clear this type of pneumonia.
We have seen a lot of recommendations of late where the coders are coding hydronephrosis, UTI and ureteral stone separately or not with the correct code to include all conditions.
Coders have struggled for some time with the dilemma of when to assign the combination code of carotid stenosis, with cerebral infarction (i.e.I63.231) and when to assign separate codes for the specific cerebral infarction and carotid stenosis. (i.e. I66.01 and I65.21).
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.
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 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…
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…
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.
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.
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.