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

An Ounce of Prevention When Coding Preventive E&M Services

In previous blogs, I’ve written in detail about the different sets of exam guidelines, scoring of HPI, ROS, MDM and other details. These are the components that make up the supporting documentation for most E&M services.  There are a few exceptions, however, like critical care, facility coding, and preventive medicine.

There are many types of E&M visits, primarily separated into sick versus well visits. They can occur at the same time, but usually don’t.  Patients coming in for their annual physical usually schedule another visit to discuss any acute issues. Continue reading

HIMagine That! Don’t Just Hope…Take Action!

Donna: Sue, did you listen to the U.S. House Energy & Commerce Subcommittee hearing on health industry readiness for ICD-10 last week?

Sue: I wasn’t able to tune in as I was at a customer site that day, but I read all of the presenter remarks and watched video of the questions asked by the subcommittee and the responses from the panel of witnesses. It’s all posted on the Coalition for ICD-10 website. How about you?

Donna: I had the hearing on in the background while I was working, but I didn’t get to listen to the entire proceedings because I was on conference calls . . . you know how it goes. So what did you think? Continue reading

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


A subway train car filled with thick black smoke due to an electrical malfunction. One woman on board had difficulty breathing and collapsed to the floor of the train, unconscious. Fellow passengers began performing CPR in an effort to help the woman. Emergency workers arrived and transported the woman to the Emergency Room of a nearby hospital. Resuscitative efforts were continued to no avail and the woman expired. The Emergency Department physician recorded the following diagnoses: acute respiratory failure due to smoke inhalation.

Assign diagnosis codes for this outpatient encounter. Continue reading

E&M Coding: Promoting the Value of Coders

Because this is a new year, my mind turns to the things I’d like to change. Rather than making the tried and true, or tried and failed “New Year’s resolutions,” I like to set goals for myself. Since 2014 was difficult in terms of my health, one of my goals is to return to my previous fitness. But, I also like to think about my professional life and the goals I’d like to set within that realm. What sort of fitness can I improve on in my professional life?

The world of professional coding is changing fast. I don’t mean ICD-10. The new code set has been imminent since I started coding many, many years ago. I’m talking more about ACOs, HCCs, PBCs, and the ever present EMRs. Continue reading

Complexity Adjustment: CMS Updates I/OCE Specifications and Software

Last week, CMS published updated I/OCE specifications and software. The changes revolved around calculations of the complexity adjustment for the comprehensive APCs (C-APCs).

Bypassing the code pair ranking

The specific language change in the specifications is in Appendix L where there is a note added: “In some instances, code pair combinations specified for complexity-adjustment may have a secondary procedure with a higher rank than the primary procedure. In these cases, the rank is ignored and the complexity-adjusted APC remains assigned to the primary procedure of the code pair.” Continue reading

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


 A 72 –year old male was admitted to the hospital with a chief complaint of a  fever with a temperature of 101° F and feeling ill with worsening chills, cough, nasal congestion and body aches that began two days prior to admission. A chest x-ray revealed bilateral infiltrates in both lower lobes of the lungs. A viral culture was positive for AH3N2 influenza.  The patient received antiviral medication and supportive care.  The patient recovered enough to be discharged three days later with a diagnosis of pneumonia due to AH3N2 influenza.

Assign ICD-10 diagnosis codes for the inpatient hospitalization. Continue reading

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


A 49-year old female arrived in the trauma ED via helicopter in cardiac arrest after sustaining a stab wound to her upper torso. The patient was attacked by an unknown assailant with a knife (found at the scene) as she was walking to her car in a parking lot. The patient was unable to be resuscitated and expired. The Emergency Department physician documented the following diagnoses:

1. Penetrating laceration of anterior left thorax with near complete laceration of thoracic aorta
2. Hemopneumothorax

Assign diagnosis codes for this Emergency Department encounter. Continue reading

Cut through to the “Gut” of Accidental Lacerations

One of the most controversial complications is an accidental laceration. It is a potentially preventable complication (PPC), a complication in all surgical cohorts for Healthgrades and is a patient safety indicator (PSI 15). Additionally, PSI 15 is included in the PSI 90 composite score and is the highest weighted component (29.83%). Hence, the importance of “getting it right” cannot be underestimated.

So when should an accidental laceration be documented, coded or clarified? Continue reading

Critical Care Coding

How many of us have worked for providers who, regardless of showing them the descriptor in the CPT book, insist upon charging critical care time for a patient in the ICU? For coders, the directions are clear: Regardless of the location of the patient, if the provider treated a critically ill or critically injured patient for 30 or more minutes, it is appropriate to report that service with a critical care code. So, when we see those magic words within the provider’s note, we submit the appropriate code(s). But, some coders don’t see the record. Some are just given a charge slip with the patient’s identifying information, procedure and diagnosis information. What is the right thing to do in this case? Because the critical care reimbursement is much higher than other E&M codes, some clinics review documentation for all critical care codes before submitting. Each group must decide how to handle the coding of these services. Continue reading

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


A 70-year old man presented at an Ambulatory Surgery Center for an upper GI endoscopy to be evaluated for the cause of his recent complaints of some dysphagia. The patient received Midazolam 6mg IV and Fentanyl 100 mcg IV and Benzocaine spray was applied to the back of his throat. After obtaining informed consent, the endoscope was passed under direct vision. It was introduced through the mouth and advanced to the second part of the duodenum. A small hiatal hernia was present. A mild Schatzki ring was found at the gastroesophageal junction at 35 cm. A TTS dilator was passed through the scope. Dilation with at 15-16.5-18 mm x 240 cm CRE balloon (to a maximum balloon size of 18 mm) dilator was performed with mild treatment effect. The esophageal body mucosa appeared mildly corrugated. Biopsies were taken from the upper and lower esophagus. At that point, the patient went into cardiac arrest. We quickly removed the endoscope and began resuscitative efforts. The patient was emergently transferred to the local hospital. Postprocedure diagnoses: Schatzki ring, hiatal hernia, cardiac arrest. Continue reading