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. Roll over each object in the story to learn why

Every code counts.

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A postoperative complication such as blood loss (coded as M96.830) following a routine joint replacement surgery, without supporting documentation from the surgeon, could trigger poor quality measures.

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For example, this patient required a transfusion during a routine hip replacement and presents with symptoms of post hemorrhagic anemia. Problematic post-surgical bleeding was not noted in the medical record.

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However, an experienced coder knows a certain amount of blood loss is expected during a routine arthroplasty. If the surgeon did not note problematic post-surgical bleeding in the medical record, proper assignment would be, D62 “Acute post hemorrhagic anemia”

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Incorrectly assigning code M96.830, Postprocedural hemorrhage of a musculoskeletal structure, without supporting documentation from the surgeon, could trigger Medicare’s Hospital Compare quality measure.

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Incorrectly assigning code M96.830 could trigger AHRQ PSI 09. PSI’s are collected by CMS for future payment adjustments through the VBP, HRRP, DSH and the HAC Reduction Program. Hospitals that report excessive postoperative complications can see their reimbursements affected due to poor quality of patient care.

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