2016 OIG Work Plan Focus: Be Proactive, Lower Risk
The 2016 OIG work plan is out and plans to focus on several “hot items” such as inpatient mechanical ventilation hours, Kwashiokor’s syndrome and other high risk scenarios. Documentation for...
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Official Coding Guideline Deletion Has Largely Gone Unnoticed
On October 1, 2014 an official coding guideline that coder's have followed for years was deleted. Under Section II. Selection of the Principal Diagnosis E. While the majority of the guidelines are...
View ArticleCDI: Documenting Altered Mental Status
Many a coder has run across the diagnosis "altered mental status" on a patient chart and then scratched their head. How do I code that? It is all about the documentation. Documenting altered...
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CDI: To Query or Not to Query
Unclear code descriptions and undefined diagnostic terms abound in ICD-10 CM. How are coders and CDI speclalists to know what do do? Well again, it all goes back to the physician. Do we query or...
View ArticleI Love My Health Information Management (HIM) Career
Often times we find ourselves in a same old, same old place due to safe career choices. We find ourselves in a comfortable job where everything is familiar and routine. It’s fine for a while, but...
View ArticleICD 10 Q&A: Coding Diabetes
Question: I’m seeing a lot of physicians assigning diabetes with hyperglycemia for “uncontrolled” diabetes. Somehow this doesn’t seem right. Could someone explain to me what the criteria for...
View ArticleSepsis - Changes in ICD 10
Sepsis – every coder’s best friend! Many of us have faced the challenge of reconciling the variations that exist in defining sepsis between ICD-9, ICD-10, providers as a group, and even amongst...
View ArticleBe Specific - Even When the Provider Is Not
Often times we find that some providers are not very specific in their diagnoses documentation. This has always been a concern, however with ICD-10 implementation, specificity has never been more...
View ArticleLumbar Spinal Fusion PCS Approaches
Lumbar spinal fusions are among the most challenging procedures to code, partly because the anatomy is difficult to conceptualize and due to the variety of approaches and combinations of procedures...
View ArticleModifier 25: To Add or Not to Add - That is the Question!
As coders we face many struggles, including determining when the use of modifier 25 is appropriate. Modifier 25 was designed to indicate a significant, separately identifiable evaluation and...
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