Coding Education

HIAlearn – Coding Staff Development & Training

Unmatched industry expertise

Ensuring the educational development of your coding staff is of utmost importance. Whether you need additional focused education based on review findings or the tools to foster ongoing coder development, HIA has you covered with the latest coding updates and regulatory changes. Much of our material is approved by AHIMA and/or AAPC for CEUs. View our extensive HIAlearn library here.

HIAlearn Offerings

Education may take many avenues, including on-site visits, audio recordings and online education modules. Training can consist of one-on-one, group sessions or self-paced. Programs can be tailored to fit any time frame, from a few hours to monthly training and monitoring of new coding staff. We utilize a Learning Management System (LMS) to house coding education sessions. Individual participants are provided a username/password to access the LMS from a designated website.

 

Education Counts

Our 70-years of combined teaching experience has taught us that academic instruction fused with practical application creates a comprehensive learning experience that benefits our team and yours.

Pat Maccariella-Hafey

Pat Maccariella-Hafey

Executive Director of Education

Beth Martilik

Beth Martilik

Assistant Director of Education

Kim Carrier

Kim Carrier

Director of Coding Quality Assurance

Coder Q&A with Pat Mac: Collapse of an Endograft

Coder Q&A with Pat Mac: Collapse of an Endograft

This would be considered a “mechanical” complication of the stent graft since the MD states it is a fracture of the endograft and it is folded over on itself. I would change T82.898A TO T82.598A for Other mechanical complication of other cardiac and vascular devices and implants, initial encounter. I did not use “displacement” because the surgeon did not state that the graft was displaced, only that it collapsed upon itself causing obstruction.

Coder Q&A with Pat Mac: Coding for Newborn

Coder Q&A with Pat Mac: Coding for Newborn

There seems to be differences of opinions on the issue of a 40w0day gestation Can you clarify if P08.21 should be assigned for 40w0day infant or if it would not be assigned unless the infant’s gestation age was 40w1day or greater?

Coder Q&A with Pat Mac: Principal Dx Selection

Coder Q&A with Pat Mac: Principal Dx Selection

In this example, would it be appropriate to code the complication code T82.03XA, Leakage of heart valve prosthesis, initial encounter as the principal diagnosis over the HFpEF (heart failure exacerbation) code?

Query Tip: When to Query for Sepsis

Query Tip: When to Query for Sepsis

Coders may find situations where a patient is documented as meeting SIRS or sepsis criteria, or has some clinical indicators reflective of possible sepsis, but the physician never documents sepsis as a diagnosis. Should the coder always query for sepsis in these instances?

Query Tip: Query for Acute Kidney Injury (AKI)

Query Tip: Query for Acute Kidney Injury (AKI)

There may be instances where a coder will suspect the patient has acute kidney injury (AKI), but the physician has failed to document the diagnosis. In another scenario, the physician may have made the diagnosis, but there is a question of clinical validity. In either case, a query would be justified.

Query Tip: Query for Clinical Validation

Query Tip: Query for Clinical Validation

When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, a coder has four choices: (1) Code the diagnosis; (2) Ignore the diagnosis; (3) Generate a query to confirm clinical validation of a diagnosis; (4) Follow the facility’s escalation policy for clinical validation.

Coding Tip: Periprosthetic Fracture Reporting and Sequencing

Coding Tip: Periprosthetic Fracture Reporting and Sequencing

Osteoporosis alone is responsible for over a million fractures every year. Stress fractures are not as common but they do occur. There are more than 1 million total joint replacements in the U.S. each year, so there was a need to create codes for injuries that occur around or near the prosthesis. These are called “periprosthetic” fractures.

Coding Tip: Spinal Procedures Reported in Addition to the Fusion

Coding Tip: Spinal Procedures Reported in Addition to the Fusion

With the implementation of ICD-10-PCS more codes were developed in order to accurately report procedures. Spinal fusion coding is still a problematic coding issue and at times, even a coder’s nightmare. Coders often report only the code for the fusion thinking that one code would include all of the other procedures that are performed.

Coding Tip: “Code First” Instructional Notes in ICD-10-CM

Coding Tip: “Code First” Instructional Notes in ICD-10-CM

There are certain conditions that have instructional notes in the ICD-10-CM tabular/coding conventions that guide the coder in sequencing. This is especially true when the condition has a common manifestation or underlying conditions of a chronic disease. If there is a “code first” note in the tabular, the coder should follow this instruction and sequence the underlying etiology or chronic condition first followed by the manifestation as an additional diagnosis.

HIAlearn – Coding Staff Development & Training

Unmatched industry expertise

Ensuring the educational development of your coding staff is of utmost importance. Whether you need additional focused education based on review findings or the tools to foster ongoing coder development, HIA has you covered with the latest coding updates and regulatory changes. Much of our material is approved by AHIMA and/or AAPC for CEUs. View our extensive HIAlearn library here.

HIAlearn Offerings

Education may take many avenues, including on-site visits, audio recordings and online education modules. Training can consist of one-on-one, group sessions or self-paced. Programs can be tailored to fit any time frame, from a few hours to monthly training and monitoring of new coding staff. We utilize a Learning Management System (LMS) to house coding education sessions. Individual participants are provided a username/password to access the LMS from a designated website.

 

Education Counts

Our 92-years of combined teaching experience has taught us that academic instruction fused with practical application creates a comprehensive learning experience that benefits our team and yours.

Pat Maccariella-Hafey

Pat Maccariella-Hafey

Executive Director of Education

Coder Q&A with Pat Mac: Collapse of an Endograft

Coder Q&A with Pat Mac: Collapse of an Endograft

This would be considered a “mechanical” complication of the stent graft since the MD states it is a fracture of the endograft and it is folded over on itself. I would change T82.898A TO T82.598A for Other mechanical complication of other cardiac and vascular devices and implants, initial encounter. I did not use “displacement” because the surgeon did not state that the graft was displaced, only that it collapsed upon itself causing obstruction.

Coder Q&A with Pat Mac: Coding for Newborn

Coder Q&A with Pat Mac: Coding for Newborn

There seems to be differences of opinions on the issue of a 40w0day gestation Can you clarify if P08.21 should be assigned for 40w0day infant or if it would not be assigned unless the infant’s gestation age was 40w1day or greater?

Coder Q&A with Pat Mac: Principal Dx Selection

Coder Q&A with Pat Mac: Principal Dx Selection

In this example, would it be appropriate to code the complication code T82.03XA, Leakage of heart valve prosthesis, initial encounter as the principal diagnosis over the HFpEF (heart failure exacerbation) code?

Beth Martilik

Beth Martilik

Assistant Director of Education

Query Tip: When to Query for Sepsis

Query Tip: When to Query for Sepsis

Coders may find situations where a patient is documented as meeting SIRS or sepsis criteria, or has some clinical indicators reflective of possible sepsis, but the physician never documents sepsis as a diagnosis. Should the coder always query for sepsis in these instances?

Query Tip: Query for Acute Kidney Injury (AKI)

Query Tip: Query for Acute Kidney Injury (AKI)

There may be instances where a coder will suspect the patient has acute kidney injury (AKI), but the physician has failed to document the diagnosis. In another scenario, the physician may have made the diagnosis, but there is a question of clinical validity. In either case, a query would be justified.

Query Tip: Query for Clinical Validation

Query Tip: Query for Clinical Validation

When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, a coder has four choices: (1) Code the diagnosis; (2) Ignore the diagnosis; (3) Generate a query to confirm clinical validation of a diagnosis; (4) Follow the facility’s escalation policy for clinical validation.

Kim Carrier

Kim Carrier

Director of Coding Quality Assurance

Coding Tip: Periprosthetic Fracture Reporting and Sequencing

Coding Tip: Periprosthetic Fracture Reporting and Sequencing

Osteoporosis alone is responsible for over a million fractures every year. Stress fractures are not as common but they do occur. There are more than 1 million total joint replacements in the U.S. each year, so there was a need to create codes for injuries that occur around or near the prosthesis. These are called “periprosthetic” fractures.

Coding Tip: Spinal Procedures Reported in Addition to the Fusion

Coding Tip: Spinal Procedures Reported in Addition to the Fusion

With the implementation of ICD-10-PCS more codes were developed in order to accurately report procedures. Spinal fusion coding is still a problematic coding issue and at times, even a coder’s nightmare. Coders often report only the code for the fusion thinking that one code would include all of the other procedures that are performed.

Coding Tip: “Code First” Instructional Notes in ICD-10-CM

Coding Tip: “Code First” Instructional Notes in ICD-10-CM

There are certain conditions that have instructional notes in the ICD-10-CM tabular/coding conventions that guide the coder in sequencing. This is especially true when the condition has a common manifestation or underlying conditions of a chronic disease. If there is a “code first” note in the tabular, the coder should follow this instruction and sequence the underlying etiology or chronic condition first followed by the manifestation as an additional diagnosis.

See how HIAlearn
will benefit you

Overcome common coding challenges identified during audits and coding staff performance reviews with HIAlearn Action Plans.

See how HIAlearn
will benefit you

Overcome common coding challenges identified during audits and coding staff performance reviews with HIAlearn Action Plans.

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