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

ICD-10 coding challenge: Legionnaire’s disease


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

HIMagine That! ICD-10: Bringing it home

Donna: Sue, can you believe it? We’re going live with ICD-10 in less than two weeks – this has to be the longest pregnancy in history!

Sue: I know. You and I have been blogging about ICD-10 for what is it – three years now? What are we going to talk about after October 1st?

Donna: Plenty! But let’s not worry about that right now. I’m wondering what people are talking about in these last few weeks leading up to go-live. Continue reading

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