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

E&M coding: Element-based or time-based?

I went to see one of my physicians today. She at her computer, me in a chair, discussing the multiple medications I’m taking, and the resulting side effects. If you’re a regular reader of my blog, you’re aware of my recent health challenges. I try not to think about what it was like before having a drawer full of medicine bottles but, I’m just whining. I know I’m lucky and I know I’m basically healthy. I’m probably a bit spoiled, too. But, back to the office visit today. My doctor and I talked for a long time. We reviewed my extensive (for me) list of medications and I complained about those side effects. She proposed a different medication regimen, then we discussed the risks associated with this change. I had a lot of questions, she consulted some studies online and we talked some more. At the end of this visit, I was examined and the impression and plan were discussed. Continue reading

HIMagine That! Collaborating on ICD-10 Documentation

Donna and Sue are joined this month by fellow 3M HIS blogger Jill Devrick.

Donna: Hi Sue. How was the AHIMA-AHDI summit? Didn’t you give a presentation?

Sue: The summit was really good, and yes, Jill Devrick and I gave a presentation on how CDI professionals and Healthcare Documentation Specialists can work together to improve the content of the medical record in light of the transition to ICD-10.

Donna: So tell me more…

Sue: You know what, let’s get Jill on the line and we can both tell you about it… Continue reading

Attention Physicians and Coders: CMS’ Advanced Analytics Paying Off – Big Time

My mother taught me that it’s impolite to say “I told you so.” My daughter tells me I’m bossy and health care compliance is pretty dry (she’s trying not to be impolite and say “boring”) but when millions of dollars are connected, it’s much more interesting and news worthy.

So, sorry Mom, but I told you so and I’ve been telling you since I began blogging. And yes, big brother and his whole family are watching. Continue reading

Twenty Years of Transcription

Twenty years ago, I began my journey in healthcare documentation technology. I’ve been traveling up and down memory lane for the past few days, thinking about how the healthcare industry has changed, and healthcare documentation tools and processes along with it.

Back in the mid-90s, healthcare documentation was almost entirely created for paper, whether it be handwritten notes and forms or transcribed documentation. Many of the hospital medical transcription departments I visited at that time were transitioning from typewriters and fancier word processing units to networked workstations running our DOS-based ChartScript application. I remember transcriptionists being concerned because a computer-based transcription system could measure productivity more consistently and precisely than the manual methods employed with typewriters and word processors. Continue reading

HCCs: Don’t Underestimate Their Importance

So there are PPCs and HACs, PPRs and PPAs, PSIs and VBP just to name a few. But please don’t forget or underestimate the importance of HCCs. Why should you care about HCCs? HCCs are Hierarchical Condition Categories (there’s a mouthful). In simpler terms, HCCs are diagnoses/conditions that are present in the patient that complicate their care and management and require more resources to treat. Sounds easy enough right? Continue reading

CMS Clarifies “ICD-10 Families” and Offers Guidance on ICD-10 Flexibilities

The latest from CMS and AMA on July 6, 2015 is a bit confusing – I agree. But a clarification was released yesterday.

In case you missed the July 6, 2015 release, CMS and the AMA announced an effort to work together to help Part B providers under the Physician Fee Schedule prepare for ICD-10. CMS recognized some physician and other professional providers need additional help. To assist in the transition, CMS announced “Medicare review contractors will not deny physician or other practitioner claims billed under Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family. Continue reading

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

CHALLENGE QUESTION

A 37-year old male with a long-standing history of the diagnosis of gender identity disorder is currently undergoing counseling and medical therapy in an effort to work toward physically modifying his body to better match his psychological gender identity. The patient is scheduled to undergo an orchiectomy penectomy and surgical construction of a vagina in the near future.

Assign the ICD-10-CM code for the diagnosis of gender identity disorder.

What ICD-10-PCS code will be used for the procedure of a surgical construction of a vagina using autologous tissue procedure for this patient? Continue reading

OPPS Proposed Rule for 2016

I hope the publication of the 2016 OPPS proposed rule on July 1st did not dampen anyone’s July 4th celebration. The new rule continues the migration CMS began in 2014 to a more “prospective payment” type system. That means that there continues to be more packaging and fewer APCs.

A few specifics: Continue reading

Physicians and Coders: No More Unspecified Care

The team I work with has done an enormous amount of work translating medical necessity policies from ICD-9 to ICD-10. And we have had many discussions regarding the codes that represent “unspecified” care in ICD-10. Should they stay in the translations – or go? Is ICD-10 specific enough to cover all care and coding contingencies now?

Unspecified Defined

An internet search (don’t you love being able to search so easily?) revealed:

Un-spec-i-fied: (adjective) meaning “not stated clearly or exactly”. Synonyms: unnamed, unstated, unidentified, undesignated, undefined, unfixed, undecided, undetermined, uncertain… Continue reading

“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