The U.S. is in the middle of flu season this month and the opioid crisis appears unabated. There are several public health issues that are impacting the United States at the moment, and this article will focus on two of them: flu immunization and the opioid epidemic, in particular.   Have…

Coders are encouraged to query if not sure.The ratio of observed-to-expected deaths is considered a measure of hospital quality. Recording accurate metrics depends on capturing all relevant diagnoses to optimize the expected mortality denominator. The explanatory variables groupings of mortality modeling for institutions include both definitive diagnoses and signs/symptoms. A…

Diabetes is the leading cause of blindness among workers in the United States. November is National Diabetes Month, as well as Diabetic Eye Disease Awareness Month. Are you aware that diabetes is the leading cause of blindness among the working people of the United States? The 2019 ICD-10-CM Official Coding…

The aim of documentation is to tell the true story. Last year, I wrote a two-part series on clinical documentation integrity, specifically focusing on the emergency department (CDI in ED Part I; CDI in ED Part II). Today I will focus on how ED documentation supports medical necessity of investigative…

CMS announced on Friday a proposed rule to expand telehealth access for patients. Hospitals, doctors, and other providers seeking an edge in today’s highly competitive healthcare environment would do well to consider a smart telehealth strategy. It’s not an option anymore to think that telemedicine doesn’t fit into your practice.…

Diabetes could be a contributing factor without being the direct cause. In the first article in this series, I compared pressure ulcers and diabetic foot ulcers (the latter are considered non-pressure chronic ulcers in ICD-10-CM). My conclusion was that there is significant overlap, but heel ulcers are prime candidates to…

The five “Ws” about the flu. It is that time of year again – flu season, which occurs in the fall and winter in the United States, stretching from early October until May. For me, it was a new experience in 2018, as I got my first flu shot! I…

New coding clinic edition offers much to review and follow.Everyone in health information management (HIM), coding, and CDI (clinical documentation improvement) is abuzz about the fourth-quarter AHA (American Hospital Association) Coding Clinic on ICD-10-CM/PCS. We just received the third-quarter issue at the end of September, which everyone is still digesting.…

There is no specific code for this condition at the present time. Acute flaccid myelitis (AFM) is a rare and serious condition that affects the areas of the spinal cord called the gray matter and has been in the news recently. According to the Center of Disease Control and Prevention…

New coding clinic brings valuable guidance Those of us in the health information management (HIM) coding profession were excited to see the third-quarter issue of the American Hospital Association (AHA) Coding Clinic on ICD-10-CM/PCS come out. Contained within the 31 pages for this issue is guidance and advice on several…