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I chose the titular subject for this article because many of us have been focusing on ICD-10-CM and PCS – and while CM is used by both inpatient and outpatient coders, we may have lost sight of CPT and HCPCS.CPT and HCPCS education is as important as ICD-10, especially considering…
Live reporting from the 2016 national convention of the American Health Information Management Association (AHIMA) continues today on Talk Ten Tuesdays, the weekly Internet radio program produced by ICD10monitor.In addition to the long-running regularly scheduled Talk Ten Tuesdays broadcast heard at 10 a.m. EST, two other broadcasts will air today, with…
The use of computer-assisted coding (also known as CAC) software is becoming more widespread in the coding industry, particularly in the coding of inpatient claims.It’s not a surprising trend, really, given the many known benefits of implementing a CAC system. Computer-assisted coding software helps streamline the coding workflow, reducing backlogs…
The use of computer-assisted coding (also known as CAC) software is becoming more widespread in the coding industry, particularly in the coding of inpatient claims.It’s not a surprising trend, really, given the many known benefits of implementing a CAC system. Computer-assisted coding software helps streamline the coding workflow, reducing backlogs…
In my previous article, Aggressive Tactics by Third Party Auditors Should Make Providers Vigilant, I suggested that one of the actions to prevent unjustified clinical validation denials (CVDs) is to perform concurrent clinical documentation integrity (CDI) reviews and pre-bill audits. Permit me to expound on the role of CDI reviews in…
Live reporting from the 2016 national convention of the American Health Information Management Association (AHIMA) continues today on Talk Ten Tuesdays, the weekly Internet radio program produced by ICD10monitor.In addition to the long-running regularly scheduled Talk Ten Tuesdays broadcast heard at 10 a.m. EST, two other broadcasts will air today, with…
I chose the titular subject for this article because many of us have been focusing on ICD-10-CM and PCS – and while CM is used by both inpatient and outpatient coders, we may have lost sight of CPT and HCPCS.CPT® and HCPCS education is as important as ICD-10, especially considering the…
SPECIAL GUEST: Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS Chief Operating Officer, First Class Solutions, Inc.ALSO FEATURING: Larry Field, Larry Field DO, MBA, CHCQM, CPC, CHC, LHRM; Andres Jimenez, MD; Laurie M. Johnson, MS, RHIA, FAHIMA; and Stanley Nachimson

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Hospitals paid under the Outpatient Prospective Payment System (OPPS) could receive a rate increase of 1.6 percent starting on Jan. 1, 2017, according to the proposed rules issued by the Centers for Medicare & Medicaid Services (CMS) on July 6, 2016.All integral, ancillary, supportive, dependent, or adjunctive services will continue…
Are you an organ donor? Before October 2005, I did not think much about this question. You may ask what happened in October 2005. My cousin had a heart transplant that month. He had been on the heart transplant list since October 1996. My cousin was 45 years old and…
EDITOR’S NOTE: National Hispanic Heritage Month runs from Sept. 15 through Oct. 15. In recognizing the healthcare contributions of Hispanics, ICD10monitor reached out to Andres Jimenez, MD. His story follows, as told to Chuck Buck.He naturally considered being a physician. His father was a surgeon in the Republic of Colombia…
EDITOR’S NOTE: During a recent Talk Ten Tuesday broadcast, listeners were asked “what percent of your claims are downgraded by third-party payers?” Downgrading by third-party payers occurs when the hospital-billed DRG is changed upon review by health insurance auditors to a lower-paying DRG. The majority of those who responded, over 51 percent,…
SPECIAL GUEST James Jones, MD Vice President of Administration and Senior Medical Director of CDQI Mount Sinai Health System New York, NY GUEST CO-HOST Maria T. Bounos RN, MPM, CPC-H, PMC, CSPO Wolters KluwerALSO FEATURING Rudy Braccili, Jr., MBA, CRCE; Laurie M. Johnson, MS, RHIA, FAHIMA; Laurie A. McBrierty, MLT,…

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The Centers for Medicare & Medicaid Services (CMS) has announced that the proposed rule for bundled payments (also known as episode payments) for high-quality, coordinated cardiac and hip fracture care modules will be targeted for initial implementation in 98 randomly selected metropolitan demonstration areas starting in July 2017. The full phase-in…
Prescription Opioid and Heroin Epidemic Awareness Week was observed from Sept. 19 -25, 2016. Prescription painkillers have taken the lives of more than 165,000 Americans since 1999. And even more lives have been lost globally.President Obama is asking for $1.1 billion in federal funding to address this healthcare and community…
For coders and clinical documentation improvement (CDI) specialists, the nuances and changes regarding coding superbug infections remain as dynamic as the pathogens themselves. Medication resistance, and especially antibiotic resistance, can be a challenging issue in the coding world.The bacteria in question include enterococcus, staphylococcus, klebsiella, acinetobacter, pseudomonas, and enterobacter. In…
There were no reports of major collisions on the I-10 Thursday, Oct. 1. Computer systems failed to crash and everything was pretty much business as usual for America’s healthcare system on a day some once thought might lead to a year of calamity. It didn’t happen. Remarkable for its absence of…
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SPECIAL GUEST Sonya Manuel LPN, CCS, CCS-P, CHC, AHIMA-Approved ICD-10-CM/PCS Trainer Jzanus Consulting, New YorkALSO FEATURING Rudy Braccili, Jr., MBA, CRCE; Sandra L Brewton, RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer; and Laurie M. Johnson, MS, RHIA, FAHIMA, FAHIMA Erica Remer, MD, FACEP, CCDS

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The goal was to avert fraud, waste, and abuse.We all support that – we collectively pay for Medicare, and who likes throwing their money away?Let’s review the ideal: the patient receives excellent medical care, the provider does a good job documenting that care, the coder translates the documentation into codes…
Throughout the country, physicians have been taught to make sure that they capture all of the elements of history of present illness (HPI), review of systems (ROS), past family and social history (PFSH), and physical exam (PE). However, either they have not been taught or have failed to show that…
Of all the challenges associated with the transition to ICD-10-PCS, coding spinal fusion procedures is by far the most difficult to tackle, in this author’s opinion. Even after training, many coders still struggle with the complexities of coding these procedures. This article focuses on the importance of thoroughly reviewing operative…
Over the many weeks since the release of the updates to the ICD-10-CM Official Coding Guidelines for the 2017 fiscal year, I have had the opportunity to engage in multiple conversations about the most controversial guideline, which addresses the use of clinical indicators for code assignment.   Some of those conversations…
SPECIAL GUEST Larry Field DO, MBA, CHCQM, CPC, CHC, LHRM, ICD10 CM/PCS Trained; Baldrige Quality Trained Treasurer- American College of Physician AdvisorsALSO FEATURING Sue Bowman, MJ, RHIA, CCS, FAHIMA; Rudy Braccili, Jr., MBA, CPAM, CRCE; Sandra L Brewton, RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer; and Laurie M. Johnson, MS,…

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The 2017 Inpatient Prospective Payment System (IPPS) guidelines contain several fundamental changes, and certainly some challenges insofar as clinical documentation improvement (CDI) and coding practices are concerned.As an advocate for integration of coding guidelines into our CDI practice, the 2017 IPPS certainly offers an opportunity for tighter collaboration between the…
September 19, 2016

ICD-10: Coding the Killers

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As it does every year, the Centers for Disease Control and Prevention (CDC) recently released its list of the leading causes of death in the United States. With the transition to ICD-10 and new codes facing provider organizations looming on Oct. 1, 2016, what should coders be aware of regarding this list? A…
If you would allow me to vent a little today, then please indulge me. If you are not in the particular mood for what some might call a rant, well, you should read anyway, because this promises to be an entertaining and thought-provoking example.    The topic is a common criticism…
I often hear auditors and coding leaders say that their physicians are pretty good at listing rationale for their diagnoses of sepsis, acute respiratory failure, and encephalopathy. However, commercial insurance continues to deny their claims.They are very frustrated – and wondering if the new ICD-10-CM guideline will help. What they…
FEATURING Rudy Braccili, Jr., MBA, CRCE; Sandra L Brewton, RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer; David Glaser, Esq.; Laurie M. Johnson, MS, RHIA, FAHIMA, FAHIMA; and Stanley Nachimson

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EDITOR’S NOTE: Laurie Johnson will be reporting live from the ICD-10 Coordination and Maintenance Committee meeting getting underway today. Her report will be carried during this week’s edition of Talk Ten Tuesdays, the Internet radio broadcast produced by ICD10monitor.When are Type II myocardial infarctions (MIs) not really MIs?Intensely debated during the…
The new guideline instructing coders not to use clinical indicators for code assignment has generated considerable interest. I have received many emails from colleagues, and even some from physicians, voicing concerns or sharing enthusiasm for coding and documentation integrity.No matter what your stance is on this guideline, it is clear…
Physician practices have had nearly a year to acclimate themselves to the ICD-10 coding that took effect in October 2015. Thanks to a grace period known as ICD-10 “relaxed rules,” which were established jointly by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA), the…
FEATURING Betty B. Bibbins, MD, BSN, CHC, CI-CDI, CPEHR, CPHIT; Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, CENTC, COBGC, CPEDC, CGSC; Laurie M. Johnson, MS, RHIA, FAHIMA, FAHIMA; and Michelle Wieczorek, RN RHIT CPHQ

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EDITOR’S NOTE: This is the second piece in a series of articles on the issue of burnout among healthcare professionals – a problem leading medical experts say is not only increasing in prevalence, but also intensity. During the coming month, several of these experts will be making appearances on Talk-Ten-Tuesdays, the…
ICD10monitor and RACmonitor have been covering the controversy that the release of the 2017 ICD-10 Official Coding and Reporting Guidelines has drummed up yet again.Two excellent articles this past week were “Coding Conundrum: Clinical Indicators for Code Assignment” by Sandra Brewton, RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer; and “Developing:…
In the final rule for the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) PPS for the 2017 fiscal year, the Centers for Medicare & Medicaid Services (CMS) continues to move the Medicare program toward paying providers based on the quality, rather than the quantity, of care…
The new year for diagnosis codes begins Oct. 1, 2016. That date also marks the end to the moratorium on new codes that has been in place since Oct. 1, 2011. For the upcoming year, there are 1,974 code additions, 311 deletions, and 425 revisions. In addition to many new, more…
SPECIAL GUEST James S, Kennedy, MD, CCS, CDIPALSO FEATURING Rudy Braccili, Jr., MBA, CRCE; Sandy Brewton, RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer; Laurie M. Johnson, MS, RHIA, FAHIMA, FAHIMA; and H. Steven Moffic, MD

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With the 2017 ICD-10-CM and PCS coding update on the horizon, we in the healthcare industry have a lot to talk about.One of the most important and possibly controversial updates affects Section I of the ICD-10-CM Official Guidelines for Coding and Reporting. This new guideline, titled Code assignment and Clinical…
Renewed interest in ICD-10 education has been prompted by the announcement last Thursday from the Centers for Medicare & Medicaid Services (CMS) indicating that the Medicare ICD-10 flexibilities agreement will end and will not be extended beyond Oct. 1, 2016.CMS also stated that Medicare would not “phase in” the requirement…
The 2017 Inpatient Prospective Payment System (IPPS) final rule brings with it a number of changes that are likely to have an even bigger impact on documentation, coding, and revenue than ICD-10 itself. An unprecedented number of dramatic changes will go into effect on Oct. 1.I knew that things were…
EDITOR’S NOTE: This is the second in a series of articles on the issue of burnout among physicians – a problem leading medical experts say is not only increasing in prevalence, but also intensity. During the coming month, several of these experts will be making appearances on Talk-Ten-Tuesdays, the weekly Internet…
Renewed interest in ICD-10 education has been prompted by the announcement last Thursday from the Centers for Medicare & Medicaid Services (CMS) indicating that the Medicare ICD-10 flexibilities agreement will end and will not be extended beyond Oct. 1, 2016.CMS also stated that Medicare would not “phase in” the requirement…
SPECIAL GUEST Sue Bowman, MJ, RHIA, CCS, FAHIMA ALSO FEATURING Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer; Allen Frady, RN, BSN, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer; Laurie M. Johnson, MS, RHIA, FAHIMA, FAHIMA; and Rhonda Taller, MHA

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EDITOR’S NOTE: This is the first in a series of articles on the issue of burnout among physicians – a problem leading medical experts say is not only increasing in prevalence, but also intensity. During the coming month, several of these experts will be making appearances on Talk Ten Tuesdays, the…
One item that has not yet received much attention is a guideline addressing the ability of a facility to report or not to report a diagnosis provided by a physician.What is a facility to do when a physician documents a diagnosis that may be unsupported by the clinical circumstances reflected…
We all know how important clinical documentation is to patient care, and from a compliance standpoint, it is also crucial to auditing – but for those dealing with the financial side of healthcare, the importance may translate into reimbursement losses. Let us look at a clinical scenario.Say an 80-year-old male…
The Centers for Medicare & Medicaid Services (CMS) released the Inpatient Prospective Payment System (IPPS) final rule for the 2017 fiscal year on Aug. 2, one day after its federally mandated deadline. This final rule will be effective for inpatient discharges taking place on and after Oct. 1, 2016.There were…
SPECIAL GUEST H. Steven Moffic, MDALSO FEATURING Chris Bundy, MD, MPH; Larry Field, DO, MBA, CHCQM, CPC, CHC, LHRM ICD-10CM/PCS-Trained, Baldrige Quality Trained; Laurie M. Johnson, MS, RHIA, FAHIMA, FAHIMA; and Melissa Walton-Shirley, MD

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Well, the long-anticipated ICD-10-CM Official Coding and Reporting Guidelines for the 2017 fiscal year have been released, and there are definitely some key areas on which to focus. The Guidelines still are to be organized into sections. Section I includes the structure and conventions of the classification and general guidelines…
When I think back on all of the road trips I went on with my family when I was a child, I don’t remember how many miles we drove. We once traveled from Arizona to West Virginia – quite a long trek across the country. But what I do remember…
Last spring I wrote about the new third definition of sepsis with a fair amount of enthusiasm and excitement. From my perspective, this new definition was the answer to the ever-present criticism of sepsis criteria – namely, the notion that people who meet the criteria often are not septic. The…
Physicians can benefit from the talents of their medical assistants, and possibly in areas other than ICD-10.Medical assistants (MAs) are typically members of physician office teams. If certified, these individuals have completed a structured education program with courses in anatomy, medical terminology, coding, and disease processes. They are among the…
SPECIAL GUEST Barbara Hinkle-Azzara, RHIA, HRSALSO FEATURING Rose T. Dunn, MBA, RHIA, CPA, FACHE; Ronald Hirsch, MD, FACP, CHCQM Laurie Johnson, MS, RHIA, FAHIMA; and Stanley Nachimson

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Given the massive number of new ICD-10 codes and the Oct. 1, 2016 compliance date, HRS and ICD10monitor are producing a special-edition Internet broadcast that will focus on the imperative of pre-bill auditing.The free broadcast will air live at 1:00 p.m. on Thursday, Aug. 4. The 60-minute live event is being sponsored…
In order to determine what makes a query leading versus non-leading, I would like to use a coding question I received recently. It goes like this… “Our doctors here frequently document ‘acute respiratory distress.’ They are using J80 for this, which codes to ‘acute respiratory distress syndrome’ (ARDS).”I responded by noting that…
Though ICD-10-PCS (procedure) codes are only required for billing purposes on inpatient claims, ICD10monitor wanted to know how many of you are using them for your outpatient claims.For billing purposes, facilities are only required to code and submit CPT® codes for outpatient services; however, pre-ICD-10 implementation, many facilities captured both…
One of the most vexing issues coding professionals face when coding for infusions and drug administration is the absence of start and stop times.According to the Centers for Medicare & Medicaid Services (CMS) Transmittal 902, hospitals are to report codes that indicate the actual time in which an infusion is…
FEATURING Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, CENTC; Rose T. Dunn, MBA, RHIA, CPA, FACHE; Holly Louie, RN, CHBME; Laurie M. Johnson, MS, RHIA, FAHIMA FAHIMA; and Joseph C. Nichols, MD

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One thing always remains the same in healthcare: change. With the implementation of ICD-10 we found out how disruptive some of these changes can actually be, and it appears that this was only a precursor to even more change in healthcare, with the implementation of new quality payment initiatives.During the…
The long-awaited update to the CT lung screening national coverage determination (NCD) was finally released this month. As you may recall, current smokers who were otherwise eligible were omitted from the NCD-covered codes released last year. That is the really good news. The really bad news is that at least…
EDITOR’S NOTE: This is the final installment of a two-part series that examines episodes of care as healthcare payment model. Part I was published on July 19, 2016. The financing of healthcare is rapidly changing in this country. The Centers for Medicare and Medicaid Services (CMS) has introduced a wide array…
Excessive heat warnings and heat advisories have been published recently for much of the Great Plains, Mississippi Valley, Midwest, Ohio Valley, Mid-Atlantic states, and Southern U.S., according to the National Weather Service. The United States has also experienced dry weather this summer, and some areas are in exceptional drought, such as…
FEATURING Kathy Pride, RHIT, CPC, CCS-P, CPMA, Sandra L. Brewton, RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer; Jonathan LaFleur, BSN, RN, CCS; Laurie M. Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10 CM/PCS Trainer; Cesar M. Limjoco, MD; and Joseph C. Nichols, MD

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The changing clinical indicators for sepsis have ignited a firestorm of debate at all levels of the healthcare industry. This month’s column provides a quick review of the changes and identifies three primary impacts to clinical coding as the new guidelines phase in.Comparing sepsis indicatorsThe existing clinical indicators we have…
EDITOR’S NOTE: This is the first in a two-part series that examines episodes of care as healthcare payment model. Part II will be published on July 26, 2016.The financing of healthcare is rapidly changing in this country. The Centers for Medicare and Medicaid Services (CMS) has introduced a wide array…
EDITOR’S NOTE: Star Trek Beyond will be released on July 22, 2016. The fourth installment in the rebooted sci-fi series is to begin production on Sept. 26, 2016.If you are unfamiliar with the Star Trek brand, it began with a TV series in 1966 with William Shatner as Captain Kirk…
Last fall’s implementation of ICD-10 throughout the nation’s healthcare industry did not produce the dire financial impacts many had feared, according to new data recently unveiled by Crowe Horwath LLP.“The conversion … was expected to have far-reaching effects. Anticipated impacts included delays in billing and coding, the potential for increased…
GUEST CO-HOST Mary Beth Pace, RN, BSN, MBA, ACM, CMAC Trinity Health SPECIAL GUEST Sue Bowman, MJ, RHIA, CCS, FAHIMA ALSO FEATURING Rudy Braccili, Jr., MBA, CPAM, CRCE; Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS; Laurie A. McBrierty, MLT, ASCP; and Stanley Nachimson

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EDITOR’S NOTE: Hard on the heels of one of the deadliest Middle East bombings in more than a decade in which 175 people were killed in Baghdad on one of the final days of the Islamic holy month of Ramadan, came last week’s wave of domestic violence. So with violent demonstrations here at…
Coding Clinic is not issuing corrections stating that linkages should not be assumed for diabetes. Rather, it is confirming that this is a new era of associated relationships for diabetes. The Coding Clinic published for the second quarter of 2016 indicated that the term “with” means both “associated with” and “due…
ICD-10 implementation success to date has been a result of collaboration and leveraging technology and education. Just as we experienced with planning for the successful implementation of ICD-10, we have learned that it takes a team of healthcare colleagues working together and sharing expertise across the continuum of patient care…
With the release of the new ICD-10-PCS codes for the 2017 fiscal year effective October 2016, we certainly are hearing lots of discussion and opinions. There are 3,827 new hospital inpatient procedure codes, and 97 percent will update the cardiovascular and lower joint body systems, per the Centers for Medicare…
GUEST CO-HOST Mary Beth Pace, RN, BSN, MBA, ACM, CMAC Trinity HealthSPECIAL GUEST Sue Bowman, MJ, RHIA, CCS, FAHIMAALSO FEATURING Rudy Braccili, Jr., MBA, CPAM, CRCE; Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS; Laurie A. McBrierty, MLT, ASCP; and Stanley Nachimson

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EDITOR'S NOTE: The Centers for Disease Control and Prevention (CDC) which administers the diagnosis codes released the 2017 ICD-10-CM codes on June 24, 2016. This information can be found at https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html Since the release of the 2017 ICD-10-PCS codes, the healthcare vendor community has been waiting with bated breath for the 2017 ICD-10-CM…
EDITOR’S NOTE: The late Robert S. Gold, MD tackled the issue of sepsis even before the advent of the 1992 SIRS criteria. He made certain that healthcare professionals should be aware that capturing the true clinical picture should be first and foremost on the agenda. This is the second in…
Hematopoietic stem cells (HSCs) are produced in bone marrow. These stem cells are responsible for the constant renewal of blood, with the production of billions of blood cells every day.What is amazing about an HSC is the fact that it can differentiate itself into a variety of cells. An HSC…
In the past year, the spectacle of clashing interests, priorities, and agendas of the public and private sectors of America’s healthcare system played out in the electronic pages of ICD10monitor’s e-newsletter, which chronicled the turmoil leading to the adoption of the International Classification of Diseases, Version 10 (ICD-10).There it was…
SPECIAL TWO-PART SERIES GUEST CO-HOST Dennis R. Jones Nyack Hospital, Nyack, New York FEATURING Sue Bowman, MJ, RHIA, CCS, FAHIMA; Jon Elion, MD, FACC; Laurie Johnson, MS, RHIA, FAHIMA; and Joseph C. Nichols, MD; and Melissa Walton-Shirley, MD

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GUEST CO-HOST Dennis R. Jones Nyack Hospital, Nyack, N.Y. FEATURING Betty Bibbins, MD, BSN, CHC, C-CDI, CPEHR, CPHIT; Holly Louie, RN, CHBME; H. Steve Moffic, MD; Stephen Spain, MD, FAAFP; and Nick van Terheyden, MD

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A recent data set gathered from 300 coders at 50 health systems was revealing with regard to ICD-10 coding accuracy thus far following the October 2015 implementation. The data exposed both good news and bad news for health information management (HIM) directors and coding managers.The good news is that coding…
EDITOR’S NOTE: Last week’s nightclub shooting in Orlando once again generated a call for mental health screening to help keep firearms and assault weapons out of the hands of the mentally ill. In the aftermath of the shooting, ICD10monitor Publisher Chuck Buck checked in with nationally renowned psychiatrist H. Steven…
June 19 was Father’s Day, and the conclusion of Men’s Health Week, which was celebrated June 13 through June 19. It appears that men are not proactive in taking care of their health, as evidenced by the Agency for Healthcare Research and Quality (AHRQ) data. The following statistics have been…
Life expectancy for American males is remaining stagnant and the overall U.S. death rate recently rose for the first time in a decade, according to concerning data released by the Centers for Disease Control and Prevention (CDC) in April and June.The life expectancy data, which compared rates recorded in 2013…
June 13–19, Men’s National Health Week, is set aside to shine a light on the topic of men’s health. While there is obviously an overlap between conditions that impact men and women, there are a number of conditions that are specific to men and specific to women.To try to understand…
In advance of the upcoming national observance of Father’s Day and in recognition of Men’s Health Week, which got underway yesterday and continues through Father’s Day, ICD10monitor is producing a two-part series on men’s health.The series will air today on Talk Ten Tuesdays, the live Internet radio broadcast produced by ICD10monitor. The…