Cologuard® was approved by the FDA in August 2014 and is an easy to use, noninvasive colon cancer screening test that identifies altered DNA and/or blood in stool, which are associated with the possibility of colon cancer or precancer. DNA is continuously shed from cells in the intestinal lining and passed into the stool. Both… Read More »Coding Tip of the Month – June 2019
Topic: Traumatic Rhabdomyolysis with Acute Kidney Injury due to Acute Tubular Necrosis Scenario: 50 year old female admitted after a motor vehicle accident where she was the restrained driver Patient with abdominal pain, nausea, tachycardia, muscle pain Patient sustained a fractured fibula/tibia of right leg Fractured ulna left arm Multiple contusions and abrasions Creatinine on… Read More »Monthly CDI Discussion – Rhabdomyolysis
The Proposed Inpatient Prospective Payment System (IPPS) Rule was established on April 23, 2019. The ICD-10-CM code changes contained in the FY 2020 Proposed Rule Tables revealed 273 new codes, 21 deleted and 30 code title revisions. Just under 60% (162) of the new codes are proposed for chapters 19 Injury, poisoning and certain other… Read More »Coding Tip of the Month – May 2019
Topic: Non-infectious SIRS with organ dysfunction Scenario: 65 year old male admitted with history of alcohol abuse and HTN Patient presents with abdominal pain and vomiting for 4 days Vital signs in ED: 160/90, HR 120, RR 24, T101.7F Labs: WBC 18.0, Lactic Acid 2.6 on admit, repeat in 24 hrs. 2.0, Blood Glucose 250… Read More »Monthly CDI Discussion – Non-infectious SIRS with Organ Dysfunction
Infections Due to Vascular Catheters: The First Quarter 2019 Coding Clinic addressed several questions regarding infections due to vascular catheters. In summary the complication code should be assigned based on the location of the catheter tip rather than the function. ICD-10-CM classifies infections from a midline catheter (T82.7-) and a central venous catheter (T80.2) differently.… Read More »Coding Tip of the Month – April 2019
Topic: Brain Compression Scenario: 80 y/o m presents with c/o left sided weakness, limping, recent slurring of speech, and lethargy. Recent rollover MVC while out of the country – No CT/MRI head completed at that time. CT head reads – Large R SDH with approx. 1.3 cm midline shift and subfalcine herniation and impending transtentorial… Read More »Monthly CDI Discussion – Brain Compression
The First Quarter 2019 Coding Clinic responded to several questions in regard to which codes to report for when you have codes from both categories J43 Emphysema and J44 Other Chronic Obstructive Pulmonary Disease. The table below summarizes the clinical scenarios submitted, code recommendations and rationale. Presenting Problem Medical History Coding Clinic Response Rationale COPD… Read More »Coding Tip of the Month – March 2019
Surgical Site Infections The October 2018 updates included expansion of Subcategory T81.4, Infection following a procedure, and new codes were created to identify surgical site infections according to depth. Six codes were created to describe infections following a procedure: Code Description T81.40 Infection following a procedure, unspecified T81.41 Infection following a procedure, superficial incisional surgical… Read More »Coding Tip of the Month – February 2019
Partial Knee Joint Replacements The knee has three compartments — the medial compartment (inside aspect of the knee), the lateral compartment (outside of the knee) and the patellofemoral compartment (in front of the knee). In some knee osteoarthritis patients, only one compartment of the knee is affected. It is usually the medial compartment that is… Read More »Coding Tip of the Month – January 2019
In today’s healthcare industry, the standard, simple coding process is a thing of the past. Coding patient records has become quite complex; it is imperative that coding professionals not only work to capture the correct DRG (diagnosis-related group) assignment, but also accurate illness severity and mortality risk, as these factors directly impact organizations’ quality-based initiatives.… Read More »Concurrent Coding – Exploring the Concept