Category Archives: Coding Best Practices

Improving coding accuracy; complete and accurate coding; computer-assisted coding; CAC; remote coding; web-based coding; APR-DRGs; DRGs; diagnosis related groups

The Client Experience Summit: It’s No Longer Just for Hospitals!

May 5-7 in Salt Lake City was a fantastic time. It has been three years since 3M acquired CodeRyte and it was great to see many CodeRyte customers attending this year. Additionally, we had a full Ambulatory training track. For customers that missed it, look for your invite next year and consider joining us. Continue reading

Documentation Quality: Time to Line up the Ducks

The Joint Commission’s (TJC) current “Quick Safety” article, intended to advise healthcare organizations about safety and quality issues, is about the potential risks when technology and human workflow practices do not ensure patient documentation is accurate, complete, and understandable. Although the title of the article is, “Transcription translates to patient risk,” the gist of the article is that documentation being captured via dictation and transcription, speech recognition technology, direct entry into templates, straight typing by providers, or any other method, needs to be reviewed with utmost care to protect patients from injury and death. Continue reading

New Outpatient Evaluation & Management Codes?

On April 17 the American Academy of Family Practitioners (AAFP) reported that a coalition of providers sent a letter to CMS proposing to “redefine and reevaluate” outpatient E&M service codes. These providers include:

  • American Academy of Allergy, Asthma and Immunology
  • American Academy of Neurology
  • American College of Allergy, Asthma and Immunology
  • American College of Rheumatology
  • American Society of Hematology
  • American Psychiatric Association
  • Endocrine Society
  • Joint Council of Allergy, Asthma and Immunology on behalf of the Advocacy Council of the ACAAI
  • Society of General Internal Medicine

Continue reading

Where Would We Be Without Clinical Coders?

I’m sitting on a plane today, traveling through the air as a result of some very bright people that enabled this mode of transportation. I’m doing so safely, thanks to strict airport security practices. Many years ago, when more stringent airport security screening was established, I would listen to fellow travelers complain about the invasion of privacy, the maybe not-so-random searches and the added expense tacked on to everything. And the lines in security, oh the lines! However, as a frequent traveler I’m forever thankful for the process we flyers have to go through to ensure the safest passage possible. Continue reading

Taking a Closer Look at the March ICD-10 Coding Challenge

CHALLENGE QUESTION:

A 62-year old male who was diagnosed with pancreatic cancer two weeks ago, was admitted to the hospital with malaise, fever, and an elevated WBC of 15.21 k/uL. The patient was diagnosed with sepsis. Blood cultures were positive for carbapenem-resistant Enterobacteriaceae (CRE). Infectious Diseases was consulted. A review of the patient’s history revealed that the patient had undergone an ERCP with biopsy of the pancreas approximately two weeks ago at which time a diagnosis of cancer of the head of the pancreas was made. It was eventually determined that the patient had been contaminated with the CRE organism from the duodenoscope used during the ERCP. The patient was discharged to an extended care facility with a PICC line for ongoing IV antibiotic therapy. Assign diagnosis codes for this inpatient encounter and sequence appropriately. Continue reading

Better Living—and Documentation—Through Computer Assistance

Have you ever driven a car without power-steering? It’s quite a workout. We used to all drive without power-steering and for “entertainment” you had to spend ten minutes twisting a small dial back-and-forth trying to get a radio station to come in clearly, only to drive under a bridge and completely lose it. Now we’re on the verge of self-driving cars and I can stream an entire album saved in the cloud into my car just about anywhere and anytime I want. No more fine-tuning that pesky radio dial. Continue reading

SGR and ICD-10: Time for Spring Cleaning

It’s that time of year again. For people not working in the healthcare industry, it’s time for flowers to start blooming, windows to be opened to fresh air, swimsuit shopping and, even though we had a short-lived blizzard in Colorado yesterday, I’m ready for spring! Let the spring cleaning begin. However, there is the painful memory of last year, when ICD-10 was delayed “at least until October 1, 2015” via the SGR repeal bill, also known as the doc fix bill. I remember exactly where I was when I heard the news. Continue reading

Do You have Questions About Edits 71 and 77?

I live in the Salt Lake City area, but last week I ventured east for the public Hospital Outpatient Payment (HOP) Panel meeting at CMS. As I listened to the testimony, I thought about some of the emails I have received about OCE edits 71 (Claim Lacks required device code) and 77 (Claim Lacks allowed procedure code). I have been asked a number of questions about these edits along with requests to talk to CMS to see if they would reinstate them, or as a last resort, have 3M create similar edits. Continue reading

Data Value: Important Mammogram Coding Change

A policy and data specialist colleague of mine was working with the 2015 NCCI data and noted that CMS had, for the first time, added screening and diagnostic mammogram codes to the edit.

Specifically, CPT 77055 and 77056 and HCPCS G0204 and G0206 (diagnostic mammography) and CPT 77057 (screening mammography) and 77063 (screening digital breast tomosynthesis, bilateral) cannot be billed on the same claim on the same date of service (DOS). Continue reading

Compliance Confusion: Observation Coding

I wonder how many millions of dollars are lost due to coding errors that have nothing to do with ICD-10 but everything to do with complex and confusing requirements and new rules. I’ve said this before: I don’t believe folks make mistakes intentionally, especially when it impacts reimbursement, but I think there is a lot of coding compliance confusion. And, in my humble opinion, it’s not the coders “fault” when errors are encountered. Continue reading