There will be 392 new PCS codes; eight revision titles; and 216 deleted codes.The Centers for Medicare and Medicaid Services (CMS) has released and posted the fiscal year (FY) 2019 ICD-10-PCS (procedural coding system) changes. The files contain information on the ICD-10-PCS updates for FY 2019 that all hospital inpatient…
Is your Electronic Medical Record (EMR) system helping you pass an audit or hurting you? Editor’s Note: This is the third piece in a four-part series that examines physician documentation issues as seen by an auditor. As we dive even further into the auditing pitfalls of a physician E&M audit,…
New CMS document features gems that fill risk adjustment voids for coding rules. Coders love rules. In risk adjustment coding, we live by the Official Guidelines for Coding and Reporting, the ICD-10-CM conventions for code lookup, and the AHA Coding Clinic for ICD-10-CM and ICD-10-PCS. Too often, though, we run…
An inspiring story about rebranding a facility’s CDI department To raise a torch to the strength of women working in healthcare I must share an introductory story on the transformation of a revitalized CDI Department that has pursued success through the strength of 23 women, and the celebrations are taking…
ICD-10 codes for the top five women’s health issues are provided in this report. Heart disease, breast cancer, osteoporosis, depression, and autoimmune diseases are the top five women’s health issues, according WebMD. This article will provide information such as risk factors, treatment, and the ICD-10-CM associated codes (of course!).  …
Physician documentation issues during an audit go beyond CDI. EDITOR’S NOTE: This is the first in a four-part series that examines physician documentation issues as seen by an auditor. One of the services I offer, aside from coding and billing education, is practice audits for evaluation and management (E&M) procedural…
CCD is when the typical and customary documentation of a condition does not line up with the available codes or the indexing. Last week, I discussed the Type 2 MI issue. This week, I will address the higher-level problem of the “coding-clinical disconnect,” which I am going to refer to…
HIM coding can play a part in stopping the abuse and neglect of children Marking April as National Child Abuse Prevention Month, we note that the Center for Disease Control (CDC) reports that child abuse and neglect are significant public health issues in the United States. The CDC reports that…
It is highly recommended to self-audit first, internally, with qualified staff. EDITOR’S NOTE: This is the first in a four-part series on the importance of passing or failing an audit and avoiding being a red-flag to payers. One of the services I offer, aside from coding and billing education, is…
Type 2 MI is not a coding construct.  I received some correspondence regarding my Type 2 myocardial infarction article last week which prompted me to ponder the coding-clinical disconnect. Let us address the Type 2 MI concerns this week, and next week, I will tackle the broader picture. Historically, the…