Q&A: Documenting uncertain diagnoses
Q: If the physician documents “concerning for,” “considering,” “cannot be ruled out,” or “cannot be excluded” for a diagnosis, is that considered an uncertain diagnosis? Can those terms be coded if the...
View ArticleHealthcare News: CMS finalized coding, MS-DRG changes
CMS finalized a number of coding and MS-DRG changes as part of the fiscal year 2016 IPPS final rule, released July 31. CMS eliminated MS-DRGs 237 (major cardiovascular procedures with MCC or thoracic...
View ArticleDifferentiate between diagnostic and therapeutic Drainage procedures in...
In ICD-10-PCS, coders will report root operation Drainage when the intent of a procedure is to take or let out fluids and/or gases from a body part.The fluids or gases may be normal or abnormal....
View ArticleIdentify opportunities from audits
By Robert S. Gold, MDIt's great, identifying opportunities to teach. Whenever I do medical record audits, I always look for chances to educate coders, physicians, and/or clinical documentation...
View ArticleDefend code assignments to help improve coding quality and reduce take-backs
While some HIM professionals may feel a sense of relief knowing Recovery Audits are on hold for the remainder of 2015, they should still keep track of denials and appeals and defending code...
View ArticleNew on JustCoding Platinum!
New sample query forms in Coding Sample Policies and Forms: Pediatric queries for hypoxic ischemic encephalopathy.Karen Bridgeman, MSN, RN, clinical documentation integrity specialist at the Medical...
View ArticleICD-10 Trainer blog
Access the latest blog posts on ICD–10 Trainer, a free online forum for all matters related to ICD-10:Alligator speed bump43 days and countingTears for knee tears
View ArticleFree quiz: ICD-10-CM external cause codes for car occupant injured in...
Test your knowledge with this week’s free quiz, which ICD-10-CM external cause codes for car occupant injured in transport accident. (View)
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Mini-poll: How confident are you that your organization will be ready for...
How confident are you that your organization will be ready for ICD-10?Extremely confidentSomewhat confidentNot confident at allVote hereLast week’s mini-pollWhich aspect of evaluation and management...
View ArticleTrivia answer: ICD-10-CM code for osteonecrosis due to previous trauma of the...
Congratulations to this week’s winner, Lisa U. Owens, RHIT, CCS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer. Lisa correctly answered this question: What is the correct ICD-10-CM code for osteonecrosis...
View ArticleProduct of the week: Chronic Kidney Disease: Use Case Studies to Improve...
Coders face a daily struggle with selecting the appropriate principal diagnosis for patients with chronic kidney disease (CKD) and its complications. Coders and clinical documentation improvement...
View ArticleQ&A: Fractures in ICD-10-CM
Q: Do you have any tips for coding fractures in ICD-10-CM? We’re a little worried about the increased number of codes. A: The first rule in finding your fracture code in the index: Keep reading. Once...
View ArticleHealthcare News: CMS adds additional clinical scenario examples
CMS continues expand its ICD-10 Clinical Concepts Series for specialties on its ICD-10 page to help coders prepare for the October 1 transition.Each guide includes:Common ICD-10 codesClinical...
View ArticleDetails distinguish between ICD-10-PCS root operations Excision, Resection
A patient comes in for a biopsy of a suspicious lump in her left breast. The physician performs a biopsy, and receives the results while the patient is still in the operating room. The pathology report...
View ArticleReporting ICD-10-CM external causes is no joke
By Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainerWhen a patient suffers a traumatic injury or poisoning, we need to report how they became injured and where they...
View ArticleDon't overlook ICD-10-PCS challenges
ICD-10-PCS will completely change the way coders report inpatient procedures. With just over a month remaining before ICD-10 implementation, coders need to solidify their understanding of this new...
View ArticleNew on JustCoding Platinum!
New sample query form in Coding Sample Policies and Forms: Pediatric queries for bronchopulmonary dysplasia. Karen Bridgeman, MSN, RN, clinical documentation integrity specialist at the Medical...
View ArticleFree quiz: ICD-10-CM codes for other bacterial diseases
Test your knowledge with this week’s free quiz, which focuses on ICD-10-CM codes for other bacterial diseases. (View)
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Mini-poll: How confident are you that your organization will be ready for...
What kind of testing has your organization done for ICD-10?End-to-end testing with all payersEnd-to-end testing with a group of payersLimited testing with most payersWe aren’t doing any testingI don’t...
View ArticleTrivia question: ICD-10-CM code for congenital glaucoma
What is the correct ICD-10-CM code for congenital glaucoma? a. Q14.0b. Q14.8c. Q15.0d. Q15.8Know the answer and want to be featured in the next issue of JustCoding News: Inpatient? Contact editor...
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