Outpatient Documentation & Coding Issues, September 2023 Presented below is an analysis of new and ongoing initiatives under the Office of the Inspector General (OIG) Work Plan [1] and the Centers for Medicare & Medicaid Services (CMS) approved Recovery Audit Contractor (RAC) reviews [2] as of July 2023. The focus is on outpatient initiatives related… Read More »UASI Compliance Analysis
The Centers for Medicare & Medicaid (CMS) announced in the fiscal year 2022 Hospital Prospective Payment System final rule published on August 2,2021 that it was adopting an April 1 implementation date for ICD-10-CM and ICD-10-PCS code updates, in addition to the annual October 1 update, beginning with April 1, 2022. The April 1 implementation… Read More »Coding Tips: Maintenance of the ICD-10-CM & ICD-10-PCS Coding Systems
Topic: Clinical Validation of Acute Kidney InjuryH&P: 79 y/o F presents with cloudy urine and labored breathing. Patient has suprapubic catheter draining to bedside bag which was last changed 10 days prior per daughter. Patient started on IV ceftriaxone, IV furosemide, and 1 liter NS bolus. Suprapubic catheter was changed during hospitalization.PMH: chronic systolic CHF,… Read More »UASI CDI Monthly Scenario Discussion – Clinical Validation of Acute Kidney Injury
The WHO ICD-11 classification is very different from the 10th version that the United States modified to create the ICD-10-CM code set that is used for reporting healthcare services on claims in the US today. In monthly code comparisons, we’ve looked at codes that are pre-coordinated or post-coordinated in ICD-11 and compared them with the… Read More »Comparing Codes Across ICD Versions: Spinal stenosis
Comparing Codes Across ICD Versions: Cholecystitis with cholelithiasis By: Mary H. Stanfill, MBI, ACHIP, RHIA, CCS, CCS-P, FAHIMA The WHO ICD-11 classification is very different from the 10th version that the United States modified to create the ICD-10-CM code set that is used for reporting healthcare services on claims in the US today. One distinct… Read More »ICD-11 Monthly – August 2023
H&P: 38 y/o male presents with nausea, vomiting, dizziness, dark urine, and thigh pain after participating in a marathon. PMH: ADHD Home medications: Adderall XR 20mg once daily Vitals: HR 125, RR 23, BP 90/42 PE: lethargic, dry mucous membranes, poor skin turgor, thigh muscle pain Labs: Admission labs -calcium 7.0 mg/dl , Potassium 4.4,… Read More »UASI Monthly CDI Scenario Discussion – Rhabdomyolysis
H&P: 97yo female presented to the ER from her nursing home after developing a fever. Patient complains of a productive cough for 2 days. Patient is bedbound at the nursing home and dependent on the staff for all ADLs. Impression: Suspect pneumonia, will obtain sputum culture and start antibiotics. PMH: Dementia, severe arthritis with contractures,… Read More »UASI Monthly CDI Scenario Discussion – Functional Quadriplegia
The FY 2024 ICD-10-CM guidelines have been released and are now available for review. While there aren’t a large amount of guideline changes and updates, there are several notable highlights in Section C, Chapter-Specific Coding Guidelines to be aware of: The complete ICD-10-CM Official Guidelines for Coding and Reporting document can be found at :… Read More »FY 2024 ICD-10-CM Official Guidelines for Coding and Reporting
H&P: 78 yr. old female admitted with abdominal pain. Caregiver states the patient is complaining of abdominal pain, and only 75mL of cloudy urine emptied from her suprapubic catheter overnight. PMH: recurrent UTI, cerebral palsy with chronic contractures, urethral stricture with chronic suprapubic catheter, seizure d/o. Home medications: Lisinopril po, Loratadine po, Methocarbamol po, Phenobarbital… Read More »UASI Monthly CDI Scenario Discussion: Catheter Associated Urinary Tract Infection (CAUTI)
The WHO ICD-11 classification is very different from the 10th version that the United States modified to create the ICD-10-CM code set that is used for reporting healthcare services on claims in the US today. One distinct difference is ICD-11 codes can be either pre-coordinated or post-coordinated, whereas all ICD-10-CM codes are post-coordinated. Let’s compare… Read More »Comparing Codes Across ICD Versions: Coronary Artery Disease