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

Quality versus quantity…a real dilemma

Happy New Year to all! As we make (and break) many New Year’s resolutions this month, I’d like to talk about resolutions for quality.

I appreciate the challenges and pressures to get claims coded and out the door and meet productivity standards. I am sure many organizations think I live in an ivory tower and not in the real world. Let me just tell you that we all have some sort of productivity standards in our jobs for which we are held accountable (myself included). Finding the right balance means hitting the mark on productivity while still doing a quality job. Continue reading

Counting down the top 5 blogs of 2015

Happy New Year to all our readers! Before the ball drops in Times Square, catch up on five of our most read blogs of the year: Continue reading

New year, new CPT modifications

Another year has come and gone and we are now entering into the most exciting time of year. Yes, that’s right, it’s CPT additions, deletions and modifications time!   Each year, coders across the United States eagerly await our new CPT books. Mine is still leaving paper dust all over my desk as I turn each newly printed page to see the updates.

Because the CPT manual puts the E&M codes in the front, I’ll list those changes first. Continue reading

Copy-paste in the EHR

Should physicians use the “copy-paste” function to document in the EHR?  In his latest blog post, 3M HIS blogger Jeremy Zasowski uses a whiteboard to sketch out the pros and cons, and offers two case studies that get to the heart of the copy-paste issue.

Watch the video here.

Copy-paste in the EHR title screen

 

Continue reading

ICD-10 coding challenge: Legionnaire’s disease

CHALLENGE QUESTION

An outbreak of Legionnaire’s disease has plagued residents of the South Bronx area of New York City this summer. At least 12 people have died from the disease and greater than 100 have been sickened by it. The source of the infection has been linked to water cooling towers in the area.

Assign the ICD-10-CM code for Legionella pneumonia. Continue reading

ICD-10: One month in

October 1, 2015 has come and gone. I didn’t really expect everything to come to a screeching halt, as warned during the anticipation of Y2K. I did, however, expect that by the middle of this month, we would have some horror stories about claims issues with regard to the transition from ICD-9 to ICD-10. I’m still waiting. I’m sure there have been individual issues, but scanning list serves, web sites, CMS, etc., I haven’t seen any systemic issues with regard to claims payment in the professional, Part B world. Insert sigh of relief here. Continue reading

What you don’t know might hurt you…the potential negative impact of CDI programs on quality outcomes data

We’ve all heard the phrase…”what you don’t know won’t hurt you.” That might be true in some settings, but in the world of documentation improvement this is definitely not the case.

Let’s look at a few commonly queried diagnoses and their impact on quality profiles. The first one is acute blood loss anemia (ABLA). Certainly this can be a diagnosis present on admission (POA), but many times it is a diagnosis clarified in the postoperative setting. And heaven forbid the provider document dilutional anemia even though it might actually be the case! On the plus side, this may increase reimbursement or impact severity of illness. On the negative side, ABLA not present on admission is a potentially preventable complication (PPC). Continue reading

Value-based care is more than the new ICD-10

I’ve heard value-based care called “the new ICD-10.” I understand the comparison, at least in reference to regulatory disruption. But aside from the CMS willpower behind value-based care, I don’t see a lot of similarities.

I think of ICD-10 as a new language that requires translation within every system using ICD codes. All system users need some level of literacy training. Value-based care is this and more. It is like moving to another state—even another country—where the customs, geography and idioms of speech are entirely different. Continue reading

Computerized Physician Order Sets for Meaningful Use – Getting Attention from LOINC and Regenstrief Institute

There’s been a lot of attention on standardizing laboratory order sets in the past year in preparation for the Meaningful Use requirements for computerized physician order sets (CPOE). The Standards & Interoperability (S&I) Framework group known as a LOINC Order Code met for fifteen months. Representatives from the Centers for Disease Control (CDC), Regenstrief Institute and various national reference laboratories and consultants were involved, with 3M as a principal participant. The group took on the scope of examining ambulatory patient laboratory orders. Continue reading

E&M coding: Incident-to vs. shared visit guidelines

I’ve written in the past about how to score the language within an E&M note. There are a number of ways to arrive at the same code, or in fact, a different code. But, there are also different types of providers and coding/billing rules associated with those different types of providers. In past blogs, I’ve written primarily about physicians as providers of care. But there are other health care members that provider E&M services, and can bill for them, but you have to know all the rules associated with each type of provider. Continue reading