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Displaying records 1 to 20 out of 8655 results for "codes that are assigned when patient record docume".
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SORT RESULTS BY: RELEVANCY | PUBLICATION DATE
By utilizing the information documented in the record, coders can report the BMI from a dietitian
Editor’s note: This is the second in a series of four articles on Patient Safety Indicat
APRIL 22, 2015
JUSTCODING
Coding for sepsis requires a strong knowledge of ICD-9-CM coding guidelines, as well as complete
DECEMBER 17, 2014
JUSTCODING
I am searching for clear, legitimate, documented guidance regarding coding for a verbal o
Query the physician to ascertain the true etiology of a patient’s gangrenous toes when the
 There are approximately 363 new codes, 142 deletions, and more than 250 code revisions in t
by Robert S. Gold, MD Do the official guidelines get in the way of ethical coding?
NOVEMBER 19, 2014
JUSTCODING
By Sharme Brodie, RN, CCDS The American Hospital Association wrapped up its Coding Cli
APRIL 8, 2015
JUSTCODING
by Megan Batty Code the fact that a patient was diagnosed as morbidly obese with
Q: Over the years I have heard differing opinions regarding whether clinical or coding exp
OCTOBER 8, 2014
JUSTCODING
Editor’s note: “Coding corner” is a monthly column written by Joan L.
While the new diagnosis code to capture COVID-19 has been in effect since April 1, coders have ru
by Megan Batty Be sure to both assign I10 (Essential (primary) hypertension) and
 by Megan Batty Code a psychiatric condition if a patient’s been diag
  To report an unspecified code or to query, that is the question. &nb
Q: The physician documented “encephalopathy” in the record of a patient who wa
Q&A: Long-term care ICD-10 coding specifics Editor's
NOVEMBER 1, 2014
Editor’s note: “Coding corner” is a monthly column written by Joan
Without Congressional action earlier this year, U.S. coders would now be using ICD-10-CM codes to
OCTOBER 8, 2014
JUSTCODING
This is the third in a series of four articles on Patient Safety Indicator (PSI) 90.
MAY 6, 2015
JUSTCODING
Q: Our electronic health record system only provides for a "yes/no" choice un
MARCH 18, 2015
JUSTCODING
Coders are tasked with telling a patient’s story based on the documentation in the m
MAY 20, 2015
JUSTCODING
If a code is incorrectly assigned or a claim is rejected, HIM and
NOVEMBER 20, 2013
JUSTCODING
by Megan Herr Incomplete information in medical records and having to call clini
A patient comes into the ED complaining of blurred vision, headache, dizziness, and numbne
MAY 20, 2015
JUSTCODING
Q: Is it appropriate to assign code Y95, nosocomial condition, based on the documentatio
NOVEMBER 20, 2013
JUSTCODING
by Megan Batty Assign a code for a patient’s body mass index (BMI) only wh
Conducting pre-billing audits can be challenging, but when done correctly, it can save organizati
To accurately interpret and code physician documentation, the HIM department should employ
JUNE 4, 2014
JUSTCODING
As of April 1, coders now have a specific ICD-10-CM diagnosis code to capture the COVID-19 virus.
The following is a deep dive into ICD-10 Return to Provider (RTP) codes, written by Renee
JANUARY 10, 2020
A complication basically refers to an unexpected result, outcome, or event. When it comes to codi
MARCH 25, 2015
JUSTCODING
  A patient presents to the ED with fever, gastroenteritis, nausea, and vomiting.
FEBRUARY 26, 2014
JUSTCODING
Q: If a patient has hypertensive heart disease or cerebrovascular accident (CVA) with hemi
  Q: Is it okay to code a diagnosis if the physician documents two diagnoses usin
SEPTEMBER 24, 2014
JUSTCODING
By Megan Batty Ensure that medical record documenta-tion clearly documents a canc
by Megan Batty Capture a patient’s diagnosis of dementia due to Parkinson&
Coders may find assigning codes for sepsis somewhat easier in ICD-
NOVEMBER 20, 2013
JUSTCODING
The Certified Coder Boot Camp®—Inpatient Version is an intensive coding educatio
NOVEMBER 19, 2014
JUSTCODING
Q: Although I understand that a coder cannot code from a previous encounter’s docume
Code the patient’s injury — such as a frac-ture, a laceration or a burn — and
A few days after JustCoding conducted
SEPTEMBER 16, 2015
JUSTCODING
NOVEMBER 5, 2014
JUSTCODING
by Megan Herr Industry experts believe the use of outsourced coding will grow as
Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV)
Using new combination codes for myelography with injection Q: A phys
Twenty frequently asked questions (FAQs) regarding the newly implemented ICD-10 code for COVID-19
Aftercare, or Z codes, should not be used for conditions found in Chapter 19 of the ICD-10-CM
SEPTEMBER 8, 2015
Providers need to be careful when reporting multiple services with status indicator J1 on the s
NOVEMBER 11, 2015
JUSTCODING
MARCH 11, 2015
JUSTCODING
by: Megan Herr Coding for diabetes and associated conditions can be tricky &mdas
  When outpatient hospitals and physicians switch to ICD-10-CM diagnosis codes Oct
MAY 14, 2014
JUSTCODING
In addition to extensive drug testing code changes in the CPT® Manual
One of the challenging aspects of coding arthroplasties is determining whether the procedu
AUGUST 20, 2014
JUSTCODING
We’re still living under a code freeze as we (eagerly) await ICD-10 implementation. However
Charging two initial infusions Q: A patient comes in for an infusion of a
by Megan Herr Muscle weakness is one of the most commonly seen and assigned prim
ICD-10 implementation and coding present plenty of challenges, especially when it comes to ICD-10
SEPTEMBER 24, 2014
JUSTCODING
by Josh Poltilove and Megan Batty If you’re commonly assigning codes N39.0
Despite there being a number of methods to correctly identify patients, wrong-patient procedures
OCTOBER 1, 2018
Q: A patient is admitted with a high white blood count, tachycardia, tachypnea, and chi
APRIL 23, 2014
JUSTCODING
by Trey La Charité, MD When providers use different definitions for the same disea
APRIL 22, 2015
JUSTCODING
 A patient comes into the ED with facial lacerations to the nose, scalp, and right cheek suf
APRIL 8, 2015
JUSTCODING
Q: Is it okay to code a diagnosis if the physician documents two diagnoses using
When coders run into a tough coding question, they often look for guidance in the AHA’s
Q&A: Long-term care ICD-10 coding specifics Editor's
JANUARY 1, 2015
  Why are physician queries so critical to accurate documentation and coding? The an
In the rush to complete ICD-10 coding education, documentation improvement, and system updates, H
OCTOBER 21, 2015
JUSTCODING
JULY 29, 2015
JUSTCODING
Q: I am never sure of correct sequencing when the admission is for flu, pne
The aide care plan or assignment must provide enough direction so the aide knows exactly what to
Coronary artery disease (CAD) develops when the arteries that supply the blood to the heart muscl
FEBRUARY 25, 2015
JUSTCODING
The codes for complications of pregnancy, childbirth, and the puerperium appear in Chapter
Evaluation and management (E/M) coding is a challenge for many coders, but ensuring accurate code
SEPTEMBER 22, 2015
by Megan Batty Confirm the bug responsible for a patient’s septic arthriti
ICD-9-CM and ICD-10-CM/PCS are currently under a code freeze as the industry prepares for ICD-10
MAY 6, 2015
JUSTCODING
The section of codes that expanded most in ICD-10-CM involves orthopedic injuries, especially fra
AUGUST 13, 2014
JUSTCODING
Proper documentation is critical when it comes to supporting medical necessity and providing qual
Q: A patient was in a hyperbaric oxygen chamber for eight minutes and the physician had
OCTOBER 1, 2014
JUSTCODING
Q: When atelectasis is noted on an ancillary test such as a CT scan of the abdomen or c
JANUARY 28, 2015
JUSTCODING
Many coders rely on the AHA's Coding Clinic advice to resolve sticky situ
MAY 13, 2015
JUSTCODING
FEBRUARY 11, 2015
JUSTCODING
SEPTEMBER 23, 2015
JUSTCODING
A still undetermined number of patients were affected when lab records from Community Mercy Healt
To report an unspecified code or to query, that is the question. And like so many coding question
A complication basically refers to an unexpected result, outcome, or event. When it comes to codi
Q: How many people should be involved in reviewing a medical record?
Q&A Long-term care ICD-10 coding specifics
OCTOBER 1, 2014
Coders can now appropriately assign a code for diastolic or systolic heart failure, as warranted
Q: Can you code strictly from emergency department (ED) documentation? Can you code from tes
DECEMBER 16, 2015
JUSTCODING
By Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC If you code a
JANUARY 21, 2015
JUSTCODING
Q: When a patient does presents in acute respiratory failure, as well as overdose, is it ever a
Continue to code a pressure ulcer treated with a skin graft as a pressure ulcer that’s unst
  An elderly patient comes into the ED with a hip fracture. Is the fracture trauma
JULY 30, 2014
JUSTCODING
Q: We had a question regarding documentation in a record of SIRS due to acute peritonit
MAY 21, 2014
JUSTCODING
OCTOBER 28, 2015
JUSTCODING
As our industry rapidly changes, so too must our patient-care policies, standards, and practices.
ImproperICD-9-CM code assignment led to incorrect grouping of claims to MS-DRG 857 (postop
JULY 30, 2014
JUSTCODING
Q: Are records with only one MCC noted targeted by Recovery Auditors or other audit agenci
Q: If a patient is given Reglan® intravenously at 12:20, 13:00, and 13:2
APRIL 15, 2015
JUSTCODING
There has been a fair amount of coverage on the documentation requirements needed to assign ICD-1
Cardiovascular disease coding in ICD-10-CM will function very similarly to the way it does in ICD
MARCH 26, 2014
JUSTCODING
Coders can breathe easy, because the codes for reporting diseases of the respiratory system (J00-
MARCH 19, 2014
JUSTCODING
The changes to fracture coding in ICD-10-CM have received plenty of attention since coders first
OCTOBER 22, 2014
JUSTCODING
FEBRUARY 11, 2015
JUSTCODING
Electronic health records (EHR) have slowly made their way into long-term care (LTC), with
DECEMBER 23, 2016
Recording use, abuse, and dependence for tobacco use with ICD-10-CM can be difficult if yo
Usually in the ICD-10 Trainer blog, I talk about ICD-10 implementation and coding from the coder
Q: Is there guidance on reviewing a record, such as an operative note, that has not been sig
NOVEMBER 4, 2015
JUSTCODING
When Congress passed the Protecting Access to Medicare Act of 2014, it mandated at least a
MAY 7, 2014
JUSTCODING
Q: When atelectasis is noted on an ancillary test such as a CT-scan of th
Once you have arrived at work, reviewed your patient assignment, and received the shift-to-shift
NOVEMBER 4, 2019
We all know that ICD-10 codes will require more complete documentation. We’ve been t
AUGUST 26, 2015
JUSTCODING
Physicians say communicating with patients online is still a challenge but that patients are beco
“The theory was that when all providers keep electronic records and they are linked togeth
MARCH 3, 2016
Q: Is it correct to append modifier -52 (reduced services) to a procedure code when the
FEBRUARY 4, 2015
JUSTCODING
Additional police will be assigned at a Paramus, New Jersey hospital, and consultants will be hir
MAY 19, 2016
Find out how one facility created an electronic health records (EHR) solution to improve m
MAY 20, 2015
JUSTCODING
A patient comes in for a biopsy of a suspicious lump in her left breast. The physician performs a
AUGUST 26, 2015
JUSTCODING
Q: We see a lot of patients in our ED who have to be defibrillated for a cardiac arrhyt
CMS introduced several new HCPCS codes and added comprehensive APCs (C-APC), including one for ob
NOVEMBER 11, 2015
JUSTCODING
by Megan Herr When coding for diabetes with an associated manifestation, check f
JANUARY 14, 2015
JUSTCODING
NOVEMBER 19, 2014
JUSTCODING
A patient presents with knee pain and reduced mobility in the joint. He also tells the physician
MARCH 11, 2015
JUSTCODING
Outpatient procedures will still be coded using CPT®/HCPCS—the HIPAA-
The Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs.html
FEBRUARY 18, 2015
JUSTCODING
Match quality of care with respect when treating LGBTQ patients 
Q: I have a patient with Stage 4 lung cancer that presented with fatigue, cough, an
Modify the Triage by Resource Allocation for IN-patient (TRAIN) matrix to suit your facil
JANUARY 1, 2019
Modify the Triage by Resource Allocation for IN-patient (TRAIN) matrix to suit your facility&rsqu
JANUARY 1, 2019
Q: We are receiving rejections for HCPCS codes J0365 (injection, aprotonin, 10,000 kiu)
Q: A few days into the patient’s stay, an order for a Foley catheter was placed f
JUNE 18, 2014
JUSTCODING
For the first time since ICD-10 coding implementation in October 2015, the application of it in S
NOVEMBER 8, 2019
Don’t succumb to off-site, out-of-mind record storage
Q: We have a physician who is sending patients to our outpatient clinic to receive
Patients who suffer cranial injuries generally experience some level of cognitive impairment. For
NOVEMBER 19, 2014
JUSTCODING
Q: When coding excision of a breast mass with needle localization using stereotactic gu
MARCH 19, 2014
JUSTCODING
Q: A patient comes in with a malunion of a fracture. A different physician treated the patient
FEBRUARY 11, 2015
JUSTCODING
CMS released Coding/OutpatientCodeEdit/OCEQtrReleaseS
APRIL 29, 2015
JUSTCODING
A diabetic patient is admitted with gangrene. The physician does not specifically link the
MAY 21, 2014
JUSTCODING
Train staff on rules about protecting patient privacy and prepare security personnel in case they
SEPTEMBER 28, 2017
Q: Should “diabetes with gastroparesis” be coded as 536.3, diab
MAY 20, 2015
JUSTCODING
MARCH 4, 2015
JUSTCODING
  Reporting laboratory tests with 2015's new CPT codes Q:
Q: Is there guidance on reviewing a record, such as an operative (OP) note, that has
Q: I am having trouble with the procedure (PCS) coding for a perineal laceration repa
by Megan Herr Coders will now be able to assign six R-codes for  dysphagia
In early January, The Joint Commission further clarified its position on the texting of patient o
FEBRUARY 9, 2017
Q. When using the newly covered non-face-to-face prolonged service codes (99358, 99359), can you
Many coders rely on the advice in the American Hospital Association (AHA)'s Coding Clin
Monday, December 1, was World AIDS Day—a day when various social, governmental, and healthc
Coding and documentation should tell a patient's complete story. With the greater specific
Many coders rely on the AHA's Coding Clinic advice to resolve sticky situations wit
ICD-10-CM includes 68,000 codes and ICD-10-PCS features 71,924 code choices. Scary numbers, right
Q: How have you handled situations when specialty physicians and hospitalists do not ag
JULY 16, 2014
JUSTCODING
Anesthesiology residents scored lower in several performance metrics when assigned to rude operat
JUNE 13, 2019
Editor’s note: With the increased specificity required for ICD-10-CM coding, code
JUNE 25, 2014
JUSTCODING
When coders hear the term bypass, they may think first of a coronary artery bypass graft (CABG) p
DECEMBER 3, 2014
JUSTCODING
Q: When the surgeon documents excision of a complex pilonidal cyst with rhomboid flap c
JULY 8, 2015
JUSTCODING
Editor’s note: With the increased specificity required for ICD-10-CM coding, code
JULY 9, 2014
JUSTCODING
SEPTEMBER 3, 2014
JUSTCODING
Caring for the obese patient requires many special considerations. A combination of physical and
Q: We had a patient come into our ED with a severe head injury. To protect his airway,
AUGUST 5, 2015
JUSTCODING
Q: What recommendation would you give to the coder when the cli
NOVEMBER 20, 2013
JUSTCODING
Q: I am having trouble with ICD-10-PCS coding for a perineal laceration repair. Some so
OCTOBER 7, 2015
JUSTCODING
Q: We have a patient diagnosed with neuropathy due to poorly controlled insulin depende
NOVEMBER 26, 2014
JUSTCODING
 Q: I have a question about coding infusion/injections in the ED prior to a decision for
OCTOBER 28, 2015
JUSTCODING
A patient presents for an esophagogastroduodenoscopy (EGD), a diagnostic procedure that allows th
OCTOBER 22, 2014
JUSTCODING
Q: I have been told by our billers that infusion codes reported in the ED along with an
SEPTEMBER 16, 2015
JUSTCODING
Organizations often struggle to finalize charts after discharge so they can be coded in a timely
Coding tells a patient's story, based on the narrative the physician provides in his or her docum
JANUARY 28, 2015
JUSTCODING
SEPTEMBER 10, 2014
JUSTCODING
Patient misidentification is an underreported problem that still plagues healthcare. Despite elec
NOVEMBER 1, 2018
Q: I have a question regarding a National Correct Coding Initiative (NCCI) edit. I repo
MARCH 4, 2015
JUSTCODING
Editor’s note: With the increased specificity required for ICD-10-CM coding, code
AUGUST 20, 2014
JUSTCODING
SEPTEMBER 9, 2015
JUSTCODING
Q: When would we use codes from ICD-10-CM category E13 (other specified diabetes mellit
JANUARY 21, 2015
JUSTCODING
Collaboration between CDI and coding professionals used to be a contentious issue. Coders, who lo
Q: A patient comes into the ED with sickle cell crisis and is in a lot of pain. The phy
JULY 23, 2014
JUSTCODING
The Joint Commission has reversed its position on the use of text messaging to send patient care
FEBRUARY 7, 2017
A recent salary survey conducted by Medical Records Briefing found the same trends prevail
Q: We are trying to verify whether we should bill for two units of the CPT® code wh
APRIL 29, 2015
JUSTCODING
Consider this scenario: A 42-year-old female patient presents to the ED with ankle pain after fal
DECEMBER 14, 2011
From time to time, hospice patients may travel outside of their current hospice provider’s
by Joan L. Usher, BS, RHIA, ACE, president & CEO of JLU Health Record Systems in Pembroke
Q: I have a question regarding facility coding for evaluation and management (E/M) leve
AUGUST 19, 2015
JUSTCODING
From time to time, hospice patients may travel outside of their current hospice provider’s
Q: We're wondering about how to use CPT® code 73225 (magnetic resonance
AUGUST 20, 2014
JUSTCODING
Northwestern Memorial Healthcare in Chicago recently notified 2,800 patients of a breach that occ
As the use of electronic health records (EHR) surges and organizations work toward meaningful use
Q: When coding a drop in hematocrit (790.01, precipitous drop in hematocrit), does it need to
MARCH 25, 2015
JUSTCODING
 We had a patient that was admitted to a home health agency after a short stay in a
Physicians say communicating with patients online is still a challenge but that patients are beco
By Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I When a patient is diagnosed with an
MARCH 26, 2014
JUSTCODING
Coding tells a patient's story, based on the narrative the physician provides in his or her docum
Q: I have been told to use the general surgery CPT® codes in the 20000 series for r
APRIL 30, 2014
JUSTCODING
by Megan Batty Code only the breast neoplasm, such as C50.512 (malignant neoplasm
A patient with congenital hydrocephalus with a ventriculoperitoneal shunt is admitted due to shun
SEPTEMBER 9, 2015
JUSTCODING
by: Josh Poltilove Home health agencies spoke up in record numbers about their co
Q: When physicians continue to only document respiratory failure in the inpatien
JUNE 4, 2014
JUSTCODING
I am specifically looking for the guidance indicating that, when an OASIS assessment is n
Q: Are there any new HCPCs codes for procedures beginning October 1? &n
AM0110, Episode Timing, and M2200, Therapy Need, apply when the assessment will determine the pat
by Megan Herr Several key changes were made to coding guidance as part of the FY
Q: A patient came to the ED with shortness of breath (SOB). The admitting diagnosis was possib
APRIL 22, 2015
JUSTCODING
Q: When I try to code ileostomy take down of the small bowel resection and end-to-end anastomos
SEPTEMBER 23, 2015
JUSTCODING
This is an excerpt from patient-safety-strategies-fall-prev
NOVEMBER 15, 2018
How would we code a trip and fall over a cat in ICD-10? You wou
Q: We're not sure what to report in this situation: A patient comes to the ED and goes
SEPTEMBER 3, 2014
JUSTCODING
Q: Do you have any tips for coding fractures in ICD-10-CM? We’re a little worried
AUGUST 26, 2015
JUSTCODING
APRIL 23, 2014
JUSTCODING
APRIL 30, 2014
JUSTCODING
The pre-admission process will take on an entirely new level of importance once Patient-Driven Pa
SEPTEMBER 13, 2019
  Hospitals have long struggled under complicated guidelines for coding injection
JANUARY 7, 2015
JUSTCODING
When ICD-10 plans first became a reality, the first thing almost everyone focused on was the numb
When was the last time you reviewed ACDIS/AHIMA’s “
AUGUST 27, 2014
JUSTCODING
Q: Can healthcare providers answer questions from other providers or patients when someon
FEBRUARY 10, 2015
Q: I’m in a little debate: Does documentation of the patient’s body mass in
MAY 7, 2014
JUSTCODING
Q: I have a question regarding CPT® code 99184 (initiation
DECEMBER 10, 2014
JUSTCODING
Q: We are having trouble determining how to assign a code for a pressure ulcer that begins
by Joan L. Usher, BS, RHIA, ACE, president and CEO of JLU Health Record Systems in Pembroke,
Review supplies needed to treat potential influenza patients and ensure your patient-flow trackin
APRIL 1, 2018
Q: We have been reporting skin substitutes with the appropriate procedure codes (either
MARBLEHEAD, Mass.--HCPro, Inc. has furthered expanded into the medical coding, reimbursement, com
JUNE 15, 2006
Q: We are an independent outpatient end-stage renal disease clinic. When we administer a blo
NOVEMBER 11, 2015
JUSTCODING
HCPro, a division of BLR, announced it has entered into a partnership with Coding Strategies, Inc
SEPTEMBER 11, 2015
All patient medical record entries must be legible, complete, dated, timed, and authenticated in
Starting Oct. 1, you’ll be able to select a specific ICD-10-CM code when a patient is in re
JustCoding's Drug Administration Capture and Audit Tool provides multiple critical tools for nur
OCTOBER 23, 2019
In an effort to accommodate the latest advances in technology and make the code set easier
JULY 22, 2015
JUSTCODING
The benefits of mobility among hospitalized patients are well-known: decreased pressure ulcers,
Q: Can we report new CPT® codes 97607 (negative pressure wound therapy,
These codes play no part in supply reporting or payment. An agency reports supplies; it does not
JustCoding’s Emergency Department Coding, by Nena Scott, MSEd, RHIA, CCS,
Q: Which root operation would we use in ICD-10-PCS for a polypectomy when a biopsy is done on
APRIL 8, 2015
JUSTCODING
What to look for when updating your restraint and seclusion policies by Brian W
AUGUST 1, 2020
A password-protected unencrypted laptop containing the PHI of nearly 8,000 patients was reported
We are in the business of healthcare, and our primary goal is to help patients feel better
JUNE 18, 2014
JUSTCODING
When coders hear the term bypass, they may think first of a coronary artery bypass graft (
  Q: We are receiving denials for many of the new CPT® codes in
CMS implemented two new CPT® Category III codes originally introduced by th
In the physician office setting, coders are likely familiar with the concept of coding for
by Joan L. Usher, BS, RHIA, ACE, president & CEO of JLU Health Record Systems in Pembroke, Ma
JustCoding’s Emergency Department Coding, by Nena Scott, MSEd, RHI
Over the last decade, patient handoff procedures have become an integral part of the patient care
SEPTEMBER 30, 2015
Providers need to be careful when reporting multiple services with status indicator J1 on the s
  Q: I have been told by our billers that infusion codes reported in the ED
Seven of 10 patients seeking treatment for acute bronchitis receive a prescription for antibiotic
A patient presents to the ED with a headache, nausea, and vomiting. The physician documented that
FEBRUARY 25, 2015
JUSTCODING
ICD-10 coding: What to expect On July 31, HHS issued a rule
OCTOBER 1, 2014
Coding and billing for pregnancy brings unique challenges, including global pregnancy packages an
Give your patients the opportunity to set an agenda ahead of their office visits and you may witn
by Josh Poltilove While agencies have choices when it comes to which claim revie
Code category Y93 in ICD-10-CM provides coders with many activities to identify what exactly the
A: Based on the number of devices eligible for pass-through payment today compared to when
SEPTEMBER 30, 2015
JUSTCODING
SEPTEMBER 16, 2015
JUSTCODING
We continue our discussion on planning a move toward a just culture to improve patient safety. La
NOVEMBER 12, 2020
Patient handoffs continue to be a major concern for hospitals. In September, The Joint Commission
NOVEMBER 1, 2017
A patient comes into the ED complaining of blurred vision, headache, dizziness, and numbness in h
  The musculoskeletal system saw the largest increase in the number of new codes i
MAY 21, 2014
JUSTCODING
What additional steps, besides the use of two patient identifiers, are required when preparing to
CMS made incorrect payments to hospitals for established patient clinic visits estimated a
JANUARY 21, 2015
JUSTCODING
The team at JustCoding is proud to announce a revamped and redesigned website launching soon. The
DECEMBER 16, 2015
JUSTCODING
About Us
SEPTEMBER 4, 2008
The electronic health record has been a game-changer for CDI specialists, automating review proce
When Congress delayed ICD-10 implementation earlier this year, provider timelines for prep
NOVEMBER 26, 2014
JUSTCODING
Drug dosage errors as a result of confusion when healthcare providers incorrectly convert patient
MAY 5, 2015
  The term “fetal distress” can be very misleading when coding for pre
MARCH 4, 2015
JUSTCODING
Despite the onset of electronic medical records and other ways of identifying patients, wrong-pat
SEPTEMBER 27, 2016
CMS has offered some clarity on what it considers to be a “family of codes” in ICD-10
What to look for when updating your restraint and seclusion policies by Brian W
SEPTEMBER 24, 2020
Editor’s note: This is the first of a series of four articles on Patient Safety I
MARCH 11, 2015
JUSTCODING
Q: I have a question about reporting drug tests to CMS for CPT® codes th
Editor’s note: “Coding corner” is a monthly column written by Joan L. Usher
Every patient who is admitted to the hospital has a principal diagnosis—the reason that occ
JANUARY 28, 2015
JUSTCODING
Become a pro at assigning, verifying, and auditing E/M codes The
SEPTEMBER 8, 2015
by Marla Durben Hirsch If you haven’t suffered a breach of patient protect
Use modifier -59 (distinct procedural service) only when appropriate to bypass medically u
AUGUST 19, 2015
JUSTCODING
Editor’s note: This is the first in a two-part series on the ICD-10-CM Z codes. The sec
DECEMBER 17, 2014
JUSTCODING
NOVEMBER 20, 2013
JUSTCODING
  CMS' 2014 IPPS final rule redefined inpatient admissions when it implemented the
CMS proposed a new HCPCS modifier be appended to every code for a service furnished in a h
FEBRUARY 4, 2015
JUSTCODING
Coders prepared for 2017 with numerous changes to the Official Coding Guidelines for the ICD-
A password-protected unencrypted laptop containing the PHI of approximately 8,000 patients was re
Correct coding is important to physician practices. The ICD-10-CM diagnoses and the CPT procedure
This payment occurs when a patient is transferred/discharged and readmitted to the same home heal
Codes for reporting conditions relating to the endocrine system are located in Chapter 4 o
When clinicians walk into a patient’s room at Brigham and Women’s Hospital in Boston
JULY 28, 2016
In 2017, a Missouri hospital found out the hard way that when not addressed quickly, restraint a
Q: How should an organization handle patient requests to withhold protected health inform
When officials at a California hospital suspected that someone was stealing drugs from anesthesia
MAY 12, 2016
Can predictive analytics push patient safety into the 21st century? Experts say n
DECEMBER 23, 2014
JUSTCODING
Q. Can facilities require a patient to take a photo for the patient’s medical recor
SEPTEMBER 18, 2017
Communication and visit satisfaction increased for physicians and patients when patients type an
Have you started dual coding for ICD-9 and ICD-10? Two facilities shared their experiences during
In November 2013, when Richard Shannon, MD, arrived to his newly appointed position as executive
OCTOBER 28, 2014
Become a pro at assigning, verifying, and auditing E/M codes. The
The death of a hospital patient last week in Bend, Oregon occurred because a pharmacy worker inad
DECEMBER 10, 2014
Hospitals are being fined unfairly when their patients develop blood clots, even when they can sh
AUGUST 4, 2015
by Josh Poltilove As flu season ramps up, it’s vital to ensure patients ge
Some clinicians, particularly those who have not been exposed to the latest in patient engagement
A patient comes into the ED with a left pleural effusion and left hemothorax. The physicia
AUGUST 13, 2014
JUSTCODING
Coronary artery disease (CAD) develops when the arteries that supply the blood to the heart muscl
Tobacco use and dependence can increase a patient's risk of developing respiratory illness
Q: We use a lot of skin substitutes. Where do we find a list of the new HCPCS code
It is interesting to note how often the term “intervention” is used when developing c
  When a provider fails to document whether a patient diagnosed with monoplegia ha
MAY 13, 2015
JUSTCODING
A patient’s plan of care is like a road map. It provides instructions and directions on ite
Have clinicians follow up the next day when patients have a change in pain medications or increas
DECEMBER 16, 2015
JUSTCODING
Powered by HCPro’s coding experts, Coding Membership gives your staff full access to our in
DECEMBER 23, 2014
JUSTCODING
A patient handoff (also known as transitioning) is both the act of passing a patient between car
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SEPTEMBER 4, 2008
OCTOBER 22, 2014
JUSTCODING
CMS offered some clarity on what it considers to be a family of codes in ICD-10-CM.
This September, a Missouri hospital found out the hard way that when not addressed quickly, restr
NOVEMBER 1, 2017
 The growth in the number of codes from ICD-9-CM to ICD-10-CM can largely be explained by th
SEPTEMBER 17, 2014
JUSTCODING
Medical doctors don't need to undergo a near-death experience to better engage with patients. W
JUNE 16, 2017
SEPTEMBER 24, 2014
JUSTCODING
by Brian Ward When your facility can’t access its medical records,
JANUARY 23, 2021
A patient arrives at the ED with acute respiratory failure and congestive heart failure. The pa
APRIL 23, 2014
JUSTCODING
MARCH 18, 2015
JUSTCODING
DECEMBER 3, 2014
JUSTCODING
Patients eligible for chronic care management services (CPT code 99490) are generally chronically
Direct messaging between physicians and patients has become more common in the past few years, th
For 2015, CMS identified 219 HCPCS/CPT codes as good candidates for comprehensive APCs (C-
In the Coding/OutpatientCodeEdit/Downloads/FinalSumof
OCTOBER 29, 2014
JUSTCODING
MARCH 5, 2014
JUSTCODING
When a hospice discovers a new ADR, staff should review the time frame for the ADR, assem
Q: Where can I find the vaccine code abbreviation list for the 2015 CPT®
JANUARY 7, 2015
JUSTCODING
I am coming across a few scenarios that have been tricky to code regarding spinal fusions
This pocket card will help physicians determine the appropriateness of patient status based on ex
SEPTEMBER 22, 2015
This pocket card will help physicians determine the appropriateness of patient status based on ex
OCTOBER 20, 2015
This pocket card will help physicians determine the appropriateness of patient status based on ex
NOVEMBER 3, 2015
This pocket card will help physicians determine the appropriateness of patient status based on ex
JANUARY 5, 2016
This pocket card will help physicians determine the appropriateness of patient status based on ex
DECEMBER 29, 2015
CMS hosted an ICD-10 “Code-a-thon” Monday (a title which instantly brings to mind all
Editor's note: With the increased specificity required for ICD-10-CM coding, coders nee
NOVEMBER 26, 2014
JUSTCODING
MAY 20, 2015
JUSTCODING
Coding for sepsis requires a strong knowledge of ICD-9-CM coding guidelines, as well as complete
APRIL 9, 2014
JUSTCODING
Psychiatric patients present a unique set of challenges regarding admission and management in a h
You already know that you need to be in compliance with the Life Safety Code(R)
MARCH 17, 2016
  There are instances when a patient comes in for routine preventive office visits
Hospitals in Connecticut reported record numbers of patients killed or seriously injured by hospi
JANUARY 7, 2015
A: Accessing the records of family members without a legitimate business need ma
DECEMBER 30, 2014
  Q: Did CMS add any new codes for drugs that have pass-through status this mon
Q: We are seeing a patient with Alzheimer’s disease, who was hospitalized
One of our nurses asked us what her legal risks are if something goes wrong when caring f
Q: We are coding for pain management procedures and have been doing dual coding in ICD-9-CM an
JULY 9, 2014
JUSTCODING
All of your coding education in one place! Powered by HCPro’s coding experts, Codin
Why patient engagement matters On one hand, physicians are exper
DECEMBER 13, 2016
In addition to documentation by physicians, nurses’ documentation affects patient safety,
JANUARY 8, 2020
Q: I read that CPT® code 20680 (removal of implant; deep, e.g., buried w
MAY 28, 2014
JUSTCODING
Collaboration between CDI and coding professionals used to be a contentious issue. Yet, collabora
by Joan L. Usher, BS, RHIA, ACE, president and CEO of JLU Health Record Systems in Pembro
Bring your entire team as we explore part two of our three-part patient status summer webcast ser
Clearing up MA HIPPS codes on claims An explanation is in or
OCTOBER 1, 2014
A record number of hospitals were fined by Medicare for having too many 30-day readmissions, acco
OCTOBER 7, 2014
Q: A patient is discharged from the skilled nursing facility (SNF) on day 24 and sent hom
DECEMBER 21, 2018
SEPTEMBER 23, 2015
JUSTCODING
CMS recently added HCPCS code C2644 (brachytherapy source, cesium-131 chloride solution, p
“It’s truly unfortunate when government mandates turn technology from an aid into a h
DECEMBER 17, 2015
Nurses new to home health struggle with the completion of documentation related to patient care.
CMS deleted HCPCS code C1300 (hyperbaric oxygen [HBO] under pressure, full body chamber, p
Patients routinely receive multiple drug administration services during a single encounter, which
Telehealth visits for chronically ill patients have advantages compared to in-person visits such
JUNE 25, 2020
Fracture codes in ICD-10-CM include more information than those in ICD-9-CM. ICD-10-CM fracture c
DECEMBER 3, 2014
JUSTCODING
As new hires transition through the orientation process, their assigned preceptors will be key to
When selecting an EHR vendor, don’t forget the add-ons!
APRIL 2, 2014
JUSTCODING
Join us at 1 p.m. (Eastern) Thursday, August 27, for part three of our patient status summer webc
Over-identifying sepsis and failing to code sepsis when it is present are just two of the proble
Bring your entire team as we explore part three of our three-part patient status summer we
Patient classification systems (PCS), or patient acuity systems, are used to determine workload r
JULY 21, 2016
Patient classification systems (PCS), also known as patient acuity systems, are used to assist a
SEPTEMBER 10, 2019
MARCH 19, 2014
JUSTCODING
Many facilities worry about the affect the new code set will have
 Earlier this year, The Joint Commission updated its National Patient Safety Goal (NPSG) on
DECEMBER 20, 2016
A patient has aggressive fungating breast cancer wound and had a biopsy in August 2019. H
Q: Should I query for chronic respiratory failure if the documentation indicates the patient
A recent salary survey conducted by our sister publication Medical Records Briefing found
JULY 29, 2015
JUSTCODING
The Denton County (Texas) Health Department began notifying tuberculosis (TB) clinic patients of
2015 annual update to the therapy code list released On November 14, CMS released a
by Josh Poltilove Ensure sound protocols are in place for how to respond when an
In January, CMS posted the first Patient Survey Star Rating information on the Home Health Compar
CMS’ grace period for reporting families of ICD-10-CM codes is coming to a close. Physician
SEPTEMBER 6, 2016
MAY 14, 2014
JUSTCODING
For stays in which the physician expects the patient will need less than two midnights of hospita
A new scoring system can help organizations spot patients at high risk for respiratory problems a
AUGUST 25, 2015
Physicians in Virginia mocked an unconscious colonoscopy patient, joking that he had syphilis an
  While overall electronic health record (EHR) adoption is up nationally, many phy
When the Centers for Medicare & Medicaid Ser-vices’ (CMS) new Patient Driven Payment Mo
JANUARY 11, 2019
Physician practices are working with a new set of rules when it comes to engaging patients online
Patients of the Medicare-certified agency who are under the care of a physician and receiving hom
Q: Did CMS issue any new HCPCS codes for drugs and biologicals for April 2014?
Every have one of those days when you feel like you’ll never be warm? I’m having one
Coding Clinic's Fourth Quarter 2013 issue focuses considerable attention on ICD-10-
Being professional at all times and having self-accountability is crucial when working in a SNF.
AUGUST 28, 2020
by Joan Usher Case conferences will take on increased importance when the Patien
When health information technology tools support medical diagnostic teams, they can improve diagn
OCTOBER 7, 2015
Take your coding skills to the next level with the latest training solution from HCPro! Co
FEBRUARY 18, 2015
JUSTCODING
  Take your coding skills to the next level with the latest training solution from
FEBRUARY 4, 2015
JUSTCODING
MSP claims?when billers must be detectives By Janet Potter,
Results of a longer view Patient Safety Organization (PSO) involvement is producing dir
FEBRUARY 26, 2014
Q: How have you handled situations when specialty physicians and hospitalists do
How is your organization using dual coding as a training tool for ICD-10? Code
MAY 20, 2015
JUSTCODING
Pennsylvania healthcare facilities use a wide variety of emergency codes, according to the M
MARCH 18, 2015
  Improving patient handoffs has long been on the radar of hospitals and health sy
MARCH 1, 2014
  Codes for common procedures of the skin, such as excisions, wound closures, and
APRIL 15, 2015
JUSTCODING
When did it become the home health agency’s responsibility to pay for a catheter in
Q: We’ve heard that ICD-10-CM does not include a diagnosis code to show that a laparosco
DECEMBER 3, 2014
JUSTCODING
Medicare allows electronic signatures as “alternative signatures” on clinical records
Treating patients with chronic pain is an ongoing problem for physicians in an era where millions
SEPTEMBER 18, 2017
HCPro’s Medical Records Briefing (MRB) asked HIM and release of information (ROI) pr
A female patient underwent a partial removal of her left ovary three years ago. She is now in to
SEPTEMBER 24, 2014
JUSTCODING
Q: Would it be appropriate to report CPT® code 75984 (change of percutan
FEBRUARY 18, 2015
JUSTCODING
  When it comes to medication reconciliation (also known as “med rec”),
MARCH 26, 2014
Q: If a is patient admitted with malnutrition and the physician documented the patien
There are very few times that a clinician will admit a patient and not complete some teaching. Ho
by: Megan Herr Whether to transfer a patient with a discharge or without dischar
CMS removed two add-on procedure codes from the inpatient-only list in the 2015 OPPS final
Outpatient coding and billing errors led to more than half of all automated denials by Recovery
Unfotunately we do not have answers to this yet. There are instances where coding guidance tells
When should you give a prescription to a patient? Prescription drug abuse has been on the
FEBRUARY 23, 2016
Q: I have a question regarding a National Correct Coding Initiative (NCCI) edit. I report
DECEMBER 10, 2014
JUSTCODING
The new AHA Coding Clinic for ICD-10-CM and ICD-10-PCS cleared up some confusion regarding
  When it comes to medication reconciliation (also known as “med rec”)
MARCH 1, 2014
 When are hospitals required to implement interim Life Safety Code® measures?
A new CPT® code for arthrodesis, a joint fusion technique to relieve pain,
Review how clinicians and other staff interact with patients who have communication issues, such
By: Katy Rushlau, ACDIS Editor Community. That’s what I think of when I thin
Risk: The record does not contain a legible signature with credential
DECEMBER 29, 2015
JULY 15, 2015
JUSTCODING
  The number of codes in ICD-10-CM can be overwhelming. ICD-9-CM contains just 32
APRIL 2, 2014
JUSTCODING
Both a medical necessity and a compliance requirement Involving patients in their care
FEBRUARY 1, 2018
When you ask patients why they like or dislike their physicians, they tend to focus on the physic
JULY 15, 2020
In general, the time spent reviewing and coding records has increased since ICD-10 implementation
In patient safety, when hospital accreditors take an interest in something, you should as well.
Editor's note: This is second part in a series covering changes to coding for cardiac c
JULY 8, 2015
JUSTCODING
  The sixth character of every ICD-10-PCS code denotes a device. That doesn’
FEBRUARY 12, 2014
JUSTCODING
Under CMS’ new payment model to be imple-mented October 1, 2019, the Patient-Driven Pay-men
OCTOBER 5, 2018
An incomplete medical record: demonstrates that care was incomplete
AUGUST 28, 2019
Q: Should “diabetes with gastroparesis” be coded as 536.3, diabetes with
A patient undergoes a hysterectomy and experiences post-procedural bleeding. The surgeon cauteriz
The 2015 CPT® Manual includes changes to the Digestive section to align codes for
CMS addressed a question about whether agencies should discharge a patient when a home health pat
CMS approved a new specialty designation code that will help the agency distinguish between diffe
DECEMBER 13, 2016
Collecting and assessing information on physician competence are daunting tasks. But when physic
Writing off an account is never preferable, but when an account cannot be collected, sometimes it
Recovery Auditors have uncovered incorrect secondary diagnoses in patients who underwent amputati
SEPTEMBER 24, 2014
JUSTCODING
APRIL 22, 2015
JUSTCODING
How does working in your electronic health record (EHR) compare to using paper records?
APRIL 15, 2015
JUSTCODING
How does working in your electronic health record (EHR) compare to using paper records?
APRIL 8, 2015
JUSTCODING
How does working in your electronic health record (EHR) compare to using paper records?
MARCH 25, 2015
JUSTCODING
APRIL 29, 2015
JUSTCODING
MAY 7, 2014
JUSTCODING
Plan staff activities for National Patient Safety Awareness Week
Each ICD-10-PCS code is comprised of seven characters with a specific meaning. In the Medical and
DECEMBER 17, 2014
JUSTCODING
Last week, a patient at Chambersburg Hospital in Pennsylvania was shot after a violent altercatio
NOVEMBER 10, 2016
After a five-year code freeze, the ICD-10 classification system will be back on a regular cycle f