Health Information Management

Health Information Management Articles by Topic: ICD-9-CM Coding

Q/A: May we bill an E/M code for a wound care first visit

  • APCs Weekly Monitor, Issue 44, November 6, 2009

    Q.  Several of our facilities that include hospital-based outpatient wound care clinics have...

Complications of surgery, uncertain diagnoses, and more highlight important updates for coders

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2009

    The American Hospital Association’s Coding Clinic for ICD-9-CM is one of the most important...

Update your ICD-9 knowledge

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2009

    Some of the major code groupings undergoing change this year include more specificity to the...

Prepare for ICD-10 with anatomy/physiology education

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2009

    As part of your preparation work for ICD-10, consider ways to offer coders more education on...

Briefings on Coding Compliance Strategies, November 2009

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2009

    Inside: Prepare for ICD-10 with anatomy/physiology education Determine your coders’ need...

Q/A: Calcium gluconate administration: Infusion or hydration?

  • APCs Weekly Monitor, Issue 43, October 30, 2009

    Q. A patient who has undergone a kidney transplant and has plasmapheresis intravenously receives IV...

2010 ICD-9-CM updates: Dealing with venous disease code changes

  • JustCoding News: Inpatient, Issue 44, October 28, 2009

    Robert S. Gold, MD, examines the concept of acute and chronic pulmonary embolism and thrombosis and...

Terminology used by physicians and ICD-9-CM doesn't always match up

  • JustCoding News: Inpatient, Issue 44, October 28, 2009

    Physicians may document appropriate terminology to describe a patient’s condition(s), however...

Q/A: Proper coding for multiple wounds at different sites

  • APCs Weekly Monitor, Issue 42, October 23, 2009

    Q: A patient with multiple wounds at different sites receives active wound management at one wound...

Tip: Distinguish between therapeutic and diagnostic tests

  • APCs Weekly Monitor, Issue 42, October 23, 2009

    Facilities need to have a clear understanding of when a procedure is diagnostic and when it is...

Q/A: Does physician documentation in written reports constitute an official order?

  • APCs Weekly Monitor, Issue 41, October 16, 2009

    Q: We don’t have the usual written orders for several tests. However, physicians dictate or...

Tip: Appropriately report units in excess of MUE

  • APCs Weekly Monitor, Issue 41, October 16, 2009

    In FAQ 8736, CMS instructs hospitals how to report units in excess of the medically unlikely edits...

Understand the complexity of coding for conditions that aren't named in documentation

  • JustCoding News: Inpatient, Issue 42, October 14, 2009

    Physicians may document clinical indicators of significant conditions, but they may not actually...

Healthcare News: Note changes for coding anemia due to chemotherapy

  • JustCoding News: Inpatient, Issue 42, October 14, 2009

    A recent JustCoding.com article referenced Coding Clinic advice on coding anemia secondary to...

Q/A: Billing for ED services that cross days

  • APCs Weekly Monitor, Issue 40, October 9, 2009

    Q: Patient arrives in ED September 7 at 23:00. ED clinical staff initiate an IV push and hydration...

Tip: Determine whether a colonoscopy is really a screening procedure

  • APCs Weekly Monitor, Issue 40, October 9, 2009

    Coding a screening colonoscopy should be relatively straightforward. However, the interpretation of...

Tip: Meet physician supervision requirements for diagnostic services

  • APCs Weekly Monitor, Issue 39, October 2, 2009

    How can your facility ensure compliance with the physician supervision requirements for diagnostic...

Use the 2010 IPPS final rule to lobby for more coder continuing education funds

  • Medical Records Briefing, Issue 10, October 1, 2009

    Many hospitals had feared a 1.9% reduction in payment for 2010, but they’ll actually see a...

Update: Know the changes for coding anemia due to chemotherapy

  • Briefings on Coding Compliance Strategies, Issue 10, October 1, 2009

    In the September BCCS, we published an article with Coding Clinic advice on coding anemia secondary...

Pay attention to the details to avoid upcoding

  • Briefings on Coding Compliance Strategies, Issue 10, October 1, 2009

    Although undercoding is always a concern for facilities, potential upcoding is just as serious a...

Know how code assignment affects data quality and risk adjustment

  • Briefings on Coding Compliance Strategies, Issue 10, October 1, 2009

    Coding has continually evolved over the past 10 years, and it will continue to change with the...

Use productivity benchmarks to set coding standards

  • Briefings on Coding Compliance Strategies, Issue 10, October 1, 2009

    With audit contractors scrutinizing coding accuracy and an upcoming transition to the ICD-10 coding...

Briefings on Coding Compliance Strategies, October 2009

  • Briefings on Coding Compliance Strategies, Issue 10, October 1, 2009

    Inside: Use productivity benchmarks to set coding standards Roller-coaster fall results in...

Medical Records Briefing, October 2009

  • Medical Records Briefing, Issue 10, October 1, 2009

    This month’s 16-page expanded issue includes our four-page quarterly insert that focuses on...

Tip: Stay up to date with quarterly Coding Clinic releases

  • CDI Strategies, Issue 20, October 1, 2009

    The most recent Coding Clinic, third quarter 2009, contains an entry on glioblastoma with vasogenic...

A round-up of new ICD-9 procedure codes for 2010

  • JustCoding News: Inpatient, Issue 40, September 30, 2009

    In the calm before the ICD-10 storm, CMS added 14 new ICD-9 procedure codes that take effect...

Avoid the push and pull when reporting complications of surgery

  • JustCoding News: Inpatient, Issue 40, September 30, 2009

    Reporting complications of surgery is often likened to a tug of war between hospitals and...

Coding conditions as "acute" versus "chronic"

  • HIM Connection, Issue 39, September 29, 2009

    Question: A patient came into the ER with complaints of a headache and facial pain. The ER...

Tip: Understand medically unlikely edits

  • APCs Weekly Monitor, Issue 38, September 25, 2009

    CMS created medically unlikely edits (MUEs) to ensure that providers don’t report excessive...

Effectively research your ICD-9-CM coding questions

  • HIM Connection, Issue 38, September 22, 2009

    Follow these steps when researching an ICD-9-CM coding question.

Q/A: Billing for items used with DME

  • APCs Weekly Monitor, Issue 37, September 18, 2009

    Q: We understand that we cannot charge for the use of equipment, but can we charge for the soft...

Tip: Understand Q status indicators

  • APCs Weekly Monitor, Issue 37, September 18, 2009

    Under the 2009 OPPS final rule, bundling is now subdivided into status indicators Q1, Q2, and Q3.

Decode the language of physicians: A closer look at hypotension and ACS

  • JustCoding News: Inpatient, Issue 38, September 16, 2009

    The language of the practice of medicine doesn’t always mesh with the language of coding...

Use benchmarks to set coding productivity standards

  • JustCoding News: Inpatient, Issue 38, September 16, 2009

    Recovery audit contractors are scrutinizing coding accuracy, and the transition to ICD-10 is only a...

Healthcare News: RACs announce additional issues approved for review in North Carolina, Alabama, Georgia, and other states in Regions B and C

  • JustCoding News: Inpatient, Issue 38, September 16, 2009

    On September 10, Connolly, the RAC for Region C, approved the following issues for review for...

Coding acute blood loss anemia due to patient noncompliance

  • HIM Connection, Issue 37, September 15, 2009

    QUESTION: A patient undergoes outpatient surgery and is subsequently admitted due to acute blood...

Coding incidental versus ectopic pregnancy

  • HIM Connection, Issue 36, September 8, 2009

    Q: What does an incidental pregnancy (code V22.2) mean? Is it related at all to an ectopic...

Ensure compliant coding for ARF

  • HIM Connection, Issue 36, September 8, 2009

    The following ICD-9-CM codes denote acute respiratory failure (ARF): 518.81, ARF...

Q/A: Reporting code 96372 for one dose administered via two injections

  • APCs Weekly Monitor, Issue 35, September 5, 2009

    Q. A physician orders one dose of a medication to be administered intramuscularly (IM) or...

Tip: Know the general definiation of 'immediately available' for physician supervision

  • APCs Weekly Monitor, Issue 35, September 4, 2009

    In its 2010 OPPS proposed rule, CMS acknowledges never having specifically defined...

Clarification: Anemia documentation and coding presents communication hazards

  • CDI Strategies, Issue 18, September 3, 2009

    Editor’s note: The following Q&A first appeared in the August 20, 2009, edition of CDI...

What's the accuracy of your POA indicators?

  • Medical Records Briefing, Issue 9, September 1, 2009

      Just because coders have been reporting the present-on-admission (POA) indicator for nearly...

Illinois hospital ensures one-day stay compliance to avoid RACs

  • Medical Records Briefing, Issue 9, September 1, 2009

    The final phase of the national Recovery Audit Contractor (RAC) rollout began last month, and...

Medical Records Briefing, September 2009

  • Medical Records Briefing, Issue 9, September 1, 2009

    This month’s issue covers a wide variety of topics of interest to HIM directors. Our cover...

Briefings on Coding Compliance Strategies September 2009

  • Briefings on Coding Compliance Strategies, Issue 9, September 1, 2009

    In this issue, we dissect the final 2010 IPPS rule, plus discuss the three new NCDs for never...

CMS delays documentation and coding adjustment, reduces payment for common MS-DRGs

  • Briefings on Coding Compliance Strategies, Issue 9, September 1, 2009

    CMS delayed a payment reduction, but changed MS-DRG weights.

Coders need specific details before coding anemia secondary to chemotherapy

  • Briefings on Coding Compliance Strategies, Issue 9, September 1, 2009

    Our coding experts provide three questions to ask before reporting anemia secondary to chemotherapy.

New ICD-9-CM codes increase specificity

  • APC Payment Insider, Issue 9, September 1, 2009

    ICD-9 code changes increase specificity to provide more information.

Q/A: Coding for incomplete stent placement

  • APCs Weekly Monitor, Issue 32, August 21, 2009

    Q: How should we code the following scenario: A patient arrives at the catheterization laboratory...

Q/A: Limits on PET scans

  • APCs Weekly Monitor, Issue 31, August 13, 2009

    Q: Is there a limit on how frequently patients may receive PET scans, such as 78815 (Tumor...

Q/A: Report modifier -59 for EKGs performed before or after cardiac catheterization

  • APCs Weekly Monitor, Issue 30, August 7, 2009

    Q. An APC edit states that 93005 (electrocardiogram, routine EKG with at least 12 leads; tracing...

Tip: Look for injuries sustained during military service

  • APCs Weekly Monitor, Issue 30, August 7, 2009

    Coders need to be aware of a new set of E codes that detail injuries sustained by military...

CMS releases FY 2010 IPPS final rule

  • HIM Connection, Issue 31, August 4, 2009

    Though many hospitals had feared a 1.9% reduction in payment for 2010, they will actually see a...

Know the adverse effects of atrial fibrillation

  • Briefings on Coding Compliance Strategies, Issue 8, August 1, 2009

    A few months ago, I wrote a description of how atrial fibrillation (AF) with rapid ventricular...

Quick list: Eight tips to better understand CMS’ GEMs

  • Briefings on Coding Compliance Strategies, Issue 8, August 1, 2009

    To help facilities prepare for ICD-10, CMS has pub¬lished two fact sheets that provide general...

Briefings on Coding Compliance Strategies, August 2009

  • Briefings on Coding Compliance Strategies, Issue 8, August 1, 2009

    Inside: What would you do? Know your ethical obligations Improve documentation with strong CDI...

Q/A: Physical and occupational therapy in the outpatient department

  • APCs Weekly Monitor, Issue 29, July 31, 2009

    Q: What are the guidelines for physician supervision for physical therapy/occupational therapy and...

Q/A: Facility guidelines for E/M levels

  • APCs Weekly Monitor, Issue 28, July 24, 2009

    Q: I work in a hospital outpatient clinic setting. Has CMS issued a deadline for developing...

Tip: Ensure medical necessity to curb outpatient revenue loss

  • APCs Weekly Monitor, Issue 28, July 24, 2009

    Providers must ensure the medical necessity of procedures they perform. To reduce revenue loss...

Know where to look in the medical record when assigning the POA indicator

  • HIM Connection, Issue 29, July 21, 2009

    Certain areas of the patient’s record will most likely provide important clues to the coder...

Q/A: Use of modifier -25

  • APCs Weekly Monitor, Issue 28, July 17, 2009

    Q: We know we should append CPT modifier –25 to the visit level when one of our EDs or...

Tip: Consider non-coding tasks when setting coder productivity goals

  • APCs Weekly Monitor, Issue 28, July 17, 2009

    When setting productivity goals, don’t forget to include non-coding responsibilities when...

Q/A: Coding for blood glucose checks

  • APCs Weekly Monitor, Issue 27, July 10, 2009

    Q: Which CPT code is appropriate for blood glucose monitoring with a device such as...

Q/A: Appropriate use of code 96376

  • APCs Weekly Monitor, Issue 26, July 3, 2009

    Q: My question pertains to CPT code 96376 (therapeutic, prophylactic, or diagnostic injection...

Clinically Speaking: Demand a code for demand myocardial infarction

  • Briefings on Coding Compliance Strategies, Issue 7, July 1, 2009

    Each year, the Cooperating Parties make changes to various ICD-9 code sets. Most recent changes...

Is your hospital owed money for PACTs?

  • Briefings on Coding Compliance Strategies, Issue 7, July 1, 2009

    The job of the recovery audit contractors (RAC) is twofold: Identify overpayments to recoup excess...

Uncover this helpful GEM to assist with ICD-10 transition

  • Briefings on Coding Compliance Strategies, Issue 7, July 1, 2009

    Despite the fact that ICD-10 implementation is nearly three years away, CMS is ramping up its...

Briefings on Coding Compliance Strategies, July 2009

  • Briefings on Coding Compliance Strategies, Issue 7, July 1, 2009

    The transition to ICD-10 and preparing for recovery audit contractors are two big issues for...

Medical Records Briefing, July 2009

  • Medical Records Briefing, Issue 7, July 1, 2009

    This month’s expanded issue includes our 4-page quarterly insert about electronic health...

Use a change-of-status form to ensure compliance when reporting condition code 44

  • HIM Connection, Issue 26, June 30, 2009

    A change-of-status form will help ensure that a hospital meets all of the criteria for reporting...

Tip: Don't forget to monitor coding productivity standards

  • APCs Weekly Monitor, Issue 25, June 26, 2009

    Establishing coding productivity standards is a necessary and challenging aspect of managing an...

Q/A: Critical care coding

  • APCs Weekly Monitor, Issue 24, June 19, 2009

    Q: My question pertains to critical care provided in an ER at a Level 1 Trauma Center. If a patient...

CMS issues supplemental fiscal year 2010 proposed rule for long-term acute care hospitals

  • HIM Connection, Issue 24, June 16, 2009

    Q: Where can I find more information about Medicare payments proposed for long-term acute care...

2010 ICD-9 code updates now available online

  • HIM Connection, Issue 24, June 16, 2009

    The new and revised ICD-9 codes that take effect October 1 are now available online. Learn more...

Perspectives on chronic left ventricular heart failure: A coder and a physician team up to offer guidance

  • Briefings on Coding Compliance Strategies, Issue 6, June 1, 2009

    Selecting a code for a patient with heart failure used to be fairly straightforward; fewer codes...

2010 IPPS proposed rule brings historic payment lows, few coding changes

  • Briefings on Coding Compliance Strategies, Issue 6, June 1, 2009

    When CMS released its May 1 proposal, hospitals received a mixed bag of news: There are minimal...

Briefings on Coding Compliance Strategies, June 2009

  • Briefings on Coding Compliance Strategies, Issue 6, June 1, 2009

    Later than usual, CMS finally released the IPPS proposed rule for fiscal year 2010. The biggest...

Construct and maintain a hospital-specific coding manual

  • HIM Connection, Issue 20, May 19, 2009

    Every hospital should develop and maintain its own internal coding manual. It’s an essential...

OIG Work Plan: Still time to prepare

  • HIM Connection, Issue 20, May 19, 2009

    Your hospital’s HIM department has more to think about than ever before. President Obama has...

Q/A: Global payment structure and scheduled ED visits

  • APCs Weekly Monitor, Issue 19, May 15, 2009

    Q: A patient is seen in the ED for laceration repair and then returns for suture or staple removal...

Understand inpatient wound care coding for RAC audits

  • HIM Connection, Issue 19, May 12, 2009

    During the three-year RAC demonstration project, payment for several inpatient debridement...

CMS issues FY 2010 proposed rule for inpatient rehabilitation facilities

  • HIM Connection, Issue 18, May 5, 2009

    On April 28, CMS issued a proposed rule for inpatient rehabilitation facilities (IRF) for FY 2010.

ICD-9 code for cerebral occlusion, thrombotic with cerebral infarction and hypertensive cardiovascular disease

  • HIM Connection, Issue 18, May 5, 2009

    Q: What code should I report for a cerebral occlusion, thrombotic with cerebral infarction and...

CMS issues FY 2010 IPPS proposed rule

  • HIM Connection, Issue 18, May 4, 2009

    The long-awaited fiscal year (FY) 2010 Inpatient Prospective Payment System (IPPS) proposed rule is...

Coding advice about a couple colonitises

  • Briefings on Coding Compliance Strategies, Issue 5, May 1, 2009

    A variety of codes apply to certain dis¬eases of the large bowel, so it?s important to understand...

The quick list: Eight sepsis coding tips

  • Briefings on Coding Compliance Strategies, Issue 5, May 1, 2009

    Sepsis, septicemia, bacteremia and Systemic Inflamma¬tory Response Syndrome (SIRS) are...

Understand inpatient wound care coding for RAC audits

  • Briefings on Coding Compliance Strategies, Issue 5, May 1, 2009

    Two ICD-9 codes denote debridement in relation to wound care: 86.22, excisional debridement of...

Briefings on Coding Compliance Strategies, May 2009

  • Briefings on Coding Compliance Strategies, Issue 5, May 1, 2009

    Across the country, hospitals are focusing more time and energy on improving quality of care, not...

CMS pilot program targets hospitals readmissions

  • HIM Connection, Issue 17, April 28, 2009

    On April 13, CMS announced a pilot project to reduce rates of hospital readmissions. The Care...

Ensure compliance when coding nonphysician documentation

  • HIM Connection, Issue 17, April 28, 2009

    In most cases, coders should not assign codes based on documentation that does not come from a...

Tip of the week

  • APCs Weekly Monitor, Issue 16, April 17, 2009

    Everyone knows that an immense amount of teamwork is necessary for a CDI program to truly be...

Championing the compliance cause

  • APCs Weekly Monitor, Issue 16, April 17, 2009

    Christina Benjamin, MA, RHIA, CCS, CCS-P, presents several compliance traps that coders should...

Coding Shone's syndrome with subaortic stenosis and coarctation

  • HIM Connection, Issue 15, April 14, 2009

      Q: How should I code Shone’s syndrome with subaortic stenosis and coarctation...

Clearly document when sepsis or SIRS is POA

  • APCs Weekly Monitor, Issue 14, April 3, 2009

    Never assume that sepsis is present on admission (POA). Sepsis or severe sepsis may be present on...

Straight talk about uncontrolled diabetes

  • Briefings on Coding Compliance Strategies, Issue 4, April 1, 2009

    We’ve been in the medical record documentation business a long time, and we’ve heard...

Championing the compliance cause: A coder's perspective on avoiding seven potential coding traps

  • Briefings on Coding Compliance Strategies, Issue 4, April 1, 2009

    Coders have a moral and ethical responsibility to judiciously avoid reimbursement fraud and abuse...

Countdown to ICD-10: Devise a four-year training plan

  • Medical Records Briefing, Issue 4, April 1, 2009

    Although coders need not put their nose to the ICD-10 grindstone for another few years, that...

Medical Records Briefing, April 2009

  • Medical Records Briefing, Issue 4, April 1, 2009

    This month?s issue is full of time-saving tips and guidance related to Joint Commission changes...

ICD-9-CM Coordination and Maintenance Committee meeting information available

  • HIM Connection, Issue 12, March 24, 2009

    If you haven’t already viewed the handouts from the ICD-9-CM Coordination and Maintenance...

Falls, spills, and other uncodable events

  • HIM Connection, Issue 12, March 24, 2009

    By Robert S. Gold, MD Patient falls account for nearly a half-million inpatient days spent in the...

Documentation and coding for toxic metabolic encephalopathy

  • HIM Connection, Issue 10, March 10, 2009

    Q: I need further clarification regarding documentation of toxic metabolic encephalopathy. I have...

Coding an infected lumbar wound

  • HIM Connection, Issue 9, March 3, 2009

    Q: I report ICD-9 code 876.1 for an infected lumbar wound. However, when I report this code, the...

The coder’s new role in the revenue cycle

  • Briefings on Coding Compliance Strategies, Issue 3, March 1, 2009

    Without complete and ac¬curate code assignment in conjunction with timely cod¬ing and...

New guidance for coding BMI and pressure ulcers

  • Briefings on Coding Compliance Strategies, Issue 3, March 1, 2009

    Hospitals around the country face a new challenge: teaching coders that they can, in certain...

Briefings on Coding Compliance Strategies, March 2009

  • Briefings on Coding Compliance Strategies, Issue 3, March 1, 2009

    At long last, CMS announced an implementation date for ICD-10: 2013. Thought that may seem far...

ICD-10 effective October 1, 2013

  • Briefings on APCs, Issue 3, March 1, 2009

    Start your transition now. The moment HIM departments nationwide have awaited for years has arrived.

Assigning a POA indicator for diabetes that progresses from controlled to uncontrolled during a hospital stay

  • HIM Connection, Issue 6, February 10, 2009

    Q: When a patient presents with controlled diabetes that progresses to uncontrolled during a...

Low Vision Awareness Month

  • Coding Educator, Issue 2, February 9, 2009

    February is Low Vision Awareness Month, so I would like to take the opportunity to share a bit...

Coding a full-thickness burn of the colon wall with serosal irritation following a colon popectomy

  • HIM Connection, Issue 5, February 3, 2009

      Q: How do you code a full-thickness burn of the colon wall with serosal irritation...

Falls, spills, and other uncodable events 

  • Briefings on Coding Compliance Strategies, Issue 2, February 1, 2009

    Seek clarification regarding etiology  by Robert S. Gold, MD  Patient falls account for...

Take another look at observation 

  • Briefings on Coding Compliance Strategies, Issue 2, February 1, 2009

    Revisit definitions, condition code 44, and the connection to inpatient status

Callers comment on HACs during special CMS session

  • Briefings on Coding Compliance Strategies, Issue 2, February 1, 2009

    For more than a year, coders have reported the present-on-admission (POA) indicator for most...

Don't leave money on the table: Report eligible procedures under OPPS

  • Briefings on Coding Compliance Strategies, Issue 2, February 1, 2009

    Effective January 1, coders can report HCPCS code C9899 when providers implant a prosthetic device...

Ensure compliance when it comes to verbal queries

  • HIM Connection, Issue 4, January 27, 2009

    Verbal queries have the greatest liability from a legal standpoint and because they are a common...

RAC appeals on the rise according to new CMS statistics

  • HIM Connection, Issue 2, January 13, 2009

    CMS revised its July 2008 RAC appeal update to include appeals statistics through August 31, 2008.

Q&A: Querying for CHF using prior documentation

  • CDI Strategies, Issue 1, January 8, 2009

    Question: Part of our clinical support for determining the presence of congestive heart failure...

Take ownership of patients’ background health risks

  • Medical Records Briefing, Issue 1, January 1, 2009

    We all do a great job in documenting our patients’ history and physical exams. We all...

National Birth Defects Prevention Month

  • Coding Educator, Issue 1, January 1, 2009

    Birth defects are the leading cause of death in the first year of life, and approximately one in 33...

Update physician query policy in light of new AHIMA practice brief

  • Briefings on Coding Compliance Strategies, Issue 1, January 1, 2009

    Editor’s note: Last month in BCCS, we offered an overview of AHIMA’s new query brief...

Guidelines for reporting CRT-D pacemaker implantation

  • Briefings on Coding Compliance Strategies, Issue 1, January 1, 2009

    Be aware of new Coding Clinic advice Cardiac resynchronization therapy defibrillator (CRT-D...

Accurately document hemorrhage severity

  • Briefings on Coding Compliance Strategies, Issue 1, January 1, 2009

    Get to know your bleeds to ensure proper coding by Robert S. Gold, MD Consider the following...

Coding oxygen therapy

  • HIM Connection, Issue 51, December 30, 2008

    Q: I am new to the inpatient coding world and looking for information about when to code oxygen...

Coding a sprained ankle

  • HIM Connection, Issue 49, December 16, 2008

    Q: A patient is walking quickly on an icy, unsalted sidewalk so she doesn’t miss her bus. The...

Coding secondary diabetes

  • APCs Weekly Monitor, Issue 50, December 12, 2008

    Coder understanding of the origin of secondary diabetes is important to help ensure coding...

Q&A: Coding using suspected, probable diagnoses

  • CDI Strategies, Issue 25, December 11, 2008

    Where can I find documentation that says that suspected or probable diagnoses have to be in the...

Understand payment implications of the POA indicator

  • HIM Connection, Issue 48, December 9, 2008

    In Medlearn Matters SE0841, CMS outlines payment implications for each of the present on admission...

Q&A: Coding from documentation other than that of the attending physician

  • CDI Strategies, Issue 24, December 4, 2008

    When a clinical condition suggests a more specific diagnosis, and a physician from a different...

Diagnosis code for rejection of a kidney transplant

  • HIM Connection, Issue 47, December 2, 2008

    Q: A physician admits a patient for rejection of a kidney transplant the physician performed four...

CMS offers RAC details despite temporary program halt

  • Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008

    Officials answer questions during special ODF By now, one point remains clear: CMS has halted the...

New guidance may create additional query opportunities

  • Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008

    Coders and CDI specialists now have concrete guidance regarding when, how, and to whom they should...

MS-DRGs on OIG radar: Ensure compliant coding

  • Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008

    Since October 1, 2007, providers have been adapting to a revised hospital inpatient reimbursement...

CMS discusses RAC expansion, ICD-10, and never events

  • Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008

    CMS discusses RAC expansion, ICD-10, and never events CMS hosted a Hospital & Hospital Quality...

CMS issues updated payment rates and wage indexes for FY 2009: Know how to apply the new data files

  • Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008

    Hospitals have been waiting for finalized wage indexes and standardized payment rates since CMS...

Go back to the source when coding secondary diabetes

  • Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008

    As of October 1, coders began reporting new codes for secondary diabetes. To maintain coding...

Work with physicians to obtain clear-cut documentation for pressure ulcers

  • Briefings on Coding Compliance Strategies, Issue 12, December 1, 2008

    by Robert S. Gold, MD Applying the present-on-admission (POA) indicator to pressure ulcers is no...

Assigning a POA indicator for pressure ulcers that progress from one stage to the next during a hospital stay

  • HIM Connection, Issue 45, November 18, 2008

    Q: What present on admission (POA) indicator should we assign when a patient presents to the...

Q&A: Pressure ulcer POA code confusion resolved

  • CDI Strategies, Issue 23, November 13, 2008

    What present on admission (POA) indicator should we assign when a patient presents to the hospital...

How to code common winter ailments

  • Medical Records Briefing, Issue 12, November 7, 2008

    Scenario 1 A patient does not properly insulate her hands (i.e., wear gloves) while shoveling her...

Get a bloody good understanding of GI hemorrhage

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008

    Gastrointestinal (GI) bleed and its manifestations can be confusing without some insight into...

Clear up morphology and neoplasm code confusion

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008

    The ICD-9-CM Manual provides many helpful tools you can use to your advantage. For example, despite...

Brush up on the 2009 ICD-9-CM carcinoid codes

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008

    Most surgeons find carcinoid tumors incidentally, either during the postmortem exam when a patient...

Examine postoperative condition coding

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008

    Just because a physician documents a condition during the postoperative period doesn’t mean...

One-day stays

  • Briefings on Coding Compliance Strategies, Issue 11, November 1, 2008

    Forty percent of Medicare admission denials relate to improper one-day stays. If this statistic...

Coding for seizures during National Epilepsy Awareness Month

  • Coding Educator, Issue 11, November 1, 2008

    November, which is National Epilepsy Awareness month, is a great time to find out more about...

Domestic Violence Awareness Month

  • Coding Educator, Issue 10, October 1, 2008

    Every year, when the month of October arrives, my thoughts return to a time years ago when a young...

Avoid encoder traps

  • Briefings on APCs, Issue 9, September 1, 2008

    Encoders are among the most valuable coding resources on the market, but software is just one tool...

Transition to ICD-10 to include HIPAA electronic transaction standards update

  • HIPAA Weekly Advisor, Issue 35, September 1, 2008

    On August 22, HHS announced a proposed regulation to replace the ICD-9 code sets now used to report...

National Sickle Cell Awareness Month: Can you code it?

  • Coding Educator, Issue 9, September 1, 2008

    September is National Sickle Cell Awareness Month and this is the perfect opportunity to address...

Outpatient coders not exempt from the FY 2009 ICD-9 code changes

  • Briefings on APCs, Issue 8, August 1, 2008

    The National Center for Health Statistics (NCHS) released its annual ICD-9-CM code changes May 30...

Q&A: OIG considers "unbundling" fraudulent

  • APCs Weekly Monitor, Issue 22, May 30, 2008

    Part 2 of a 2-part series. See the May 23, 2008 APCs Weekly Monitor for the CMS stance on...

Q&A: CMS considers "unbundling" fraudulent

  • APCs Weekly Monitor, Issue 21, May 23, 2008

    Do CMS and the Office of Inspector General (OIG) consider the intentional unbundling of codes to be...