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

“My Patients Are Sicker”…Prove it!

When thinking of quality outcomes improvement, much focus is on the particular quality concern (such as a readmission, accidental laceration, etc.) and reducing the incidence through better practice, improved documentation or coding. But not enough attention is focused on risk-adjustment for the various quality indicators. And sadly, this is the easiest part to fix! Continue reading

HIMagine That! Coder Agreement

Donna: Sue, what results are you hearing about ICD-10 coder agreement as sites get ready to implement October 1, 2015?

Sue: What do you mean by “ICD-10 coder agreement?”

Donna: Well, as hospitals are in the homestretch of their ICD-10 preparation activities, one of the things they’re doing is having all of their coding staff code the same cases in ICD-10 so they can compare results. Continue reading

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

CHALLENGE QUESTION

A 37-year old male was found unresponsive in a bedroom at his home by a family member. Paramedics arrived and found the patient pulseless and not breathing. The patient’s skin was cool and cyanotic. The family member said the patient had been using Oxycodone for long-standing back pain for the past two to three years. A prescription bottle for the drug was found at the scene. The patient was transported to a nearby Emergency Room where he was pronounced dead. The Emergency Room physician recorded the diagnoses of: Continue reading

Millions Claimed by Lost Physicians and Coders

There was only one time in my life that I literally did not know where I was. I had just moved to Alexandria, Virginia and took a wrong turn off the Beltway. I didn’t know which state I was in until I asked at a gas station. The station attendant thought I was crazy of course, but when I explained my predicament he laughed and told me that I was actually in Maryland. Since this happened pre-GPS, he also gave me directions to get back to Virginia – but, as I said, that only happened once. Continue reading

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