RSSAll Entries in the "Coding" Category

Review the rules to master E/M coding

Even the most skilled specialists have trouble with E/M coding, says Joe Rivet, CPC, CCS-P, CICA, CEMC, a regulatory specialist at HCPro, Inc., based in Livonia, MI. The CPT Manual provides eight pages of guidelines, but this just skims the surface, he says, since the CMS requirements are even more detailed.

CDI specialists should become familiar with the CMS documentation guidelines on E/M coding, which are much lengthier and more detailed than those contained in the Manual, Rivet recommends. (Learn more about E/M guidelines on the CMS Web site.)

For example, the CPT Manual provides a definition for review of systems (ROS) and lists elements of a system review (e.g., constitutional symptoms, cardiovascular, respiratory). The 1997 Documentation Guidelines for E/M Services provides a similar definition and list of elements of a system review, too. But CMS guidelines also give detailed explanations for different levels of an ROS (e.g., problem pertinent, extended, complete) and the requirements to satisfy each level.

According to the 1997 E/M Guidelines:

A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.

“You really need to know them very well,” he says. “There’s a big difference between the AMA guidelines and CMS guidelines. The AMA provides a very skeletal version of the official rules [in the CPT Manual].”

Editor’s note: This article was adapted from a tip published on the HCPro site Click here to read this complete article in

Advice for coding educators: ‘Start ICD-10 plans now’

When should schools start teaching ICD-10-CM instead of 9?  AHIMA recommends a three-step process that starts with academic planning this fall and transitions through a hybrid educational method in 2010 and finally full ICD-10 curriculum integration by 2011. In its practice brief “Transitioning to ICD-10-CM/PCS-An Academic Timeline” published in the April edition of the Journal of AHIMA, the association recommends:

  1. Preparation- Start with the August 2009 academic school year to consider the impact of the transition and begin to formulate plans.
  2. Hybrid-Begins in the August 2010 school year because educators will face the challenge of incorporating both coding systems into an already full academic schedule.
  3. Full Implementation-Starts with the August 2011 academic year for associate and baccalaureate degree programs. This is the final stage of the curriculum change with ICD-10-CM/PCS being taught as the current classification system.

Knock, knock: Picking a principal diagnosis is no joke

There was some controversy on CDI Talk this week concerning the correct way to code a case where the patient had shortness of breath, Pneumothorax, DVT, and hypoxia. The debate centered around which diagnosis was the principal: Emboli or DVT. There were many opinions, mine included, and as the talk ensued, it made me chuckle. There did not seem to be a clear-cut answer.

We all seemed to reach separate conclusions while all doing the same jobs. We all agreed with which sequence pays the most-DVT with Pneumothorax as the MCC. And we all know which diagnosis is the most resource intensive-Pneumothorax with DVT as CC.  But nevertheless, we couldn’t agree about how to properly code this. It reminded me of an old knock, knock joke I heard as a kid.

It went something like this:

Code sequencing is no knock knock joke. It's a real compliance trick.

Anyone got this answer?

Who’s there?
Who’s where?

The Coding Guidelines state:

“When there are two or more interrelated conditions potentially meeting the definition of principal diagnoses, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.”

When sequencing fractures in the trauma setting, the most significant should be sequenced as the principal. Does this rule only apply to bones? An emboli is certainly more life threatening than a DVT.

Who’s there?
Who’s where?
Who’s right?

Code sequencing is no knock knock joke. It’s a real compliance trick. CDI specialists, coders, help us out on this one. . . 

CMS releases crosswalk for ICD-9 to ICD-10 translation

CMS released The General Equivalence Mappings – ICD-9-CM To and From ICD-10-CM and ICD-10-PCS Fact Sheet in March to assist in the conversion of ICD-9-CM to the anticipated October 1, 2013 implementation date for ICD-10-CM codes. The fact sheet explains how to translate 9 codes to 10 codes and vice versa.

CMS also release information from The General Equivalence Mappings information discussed in the fact sheet is also posted in the CMS Frequently Asked Questions database.

Coders deserve ‘superhero’ kudos

Hidden deep within the HIM office hides the coders’ universe. These hard working individuals put in long hours at small cubicles, staring at multiple computer screens. They are the unsung heroes of the hospital. This group of individuals would probably shun any fancy accolades, tell you they are simply doing their job, but this is an understatement.

Coders deserve a hero's recognition.

Coders deserve a hero's recognition.

The coder is a type of superhero, bestowed with powers beyond that of a mere mortal. Physicians frequently use abbreviations that boggle the mind. Web sites abound with dictionaries for approved abbreviations, but low and behold the physician will always come up with something new. GLM, for example, sometimes refers to a patients’ good looking mother. ARBF means awaiting return of bowel function. The list goes on and on, but curiously the coders know what the collection of symbols stand for.

Coders also decipher the worst handwriting in the universe and make sense out of the senseless. They memorize physician signatures and read words where others only see squiggles. Coders know the DRG number of most illnesses.

Hospital reimbursement would come to a standstill were it not for the coders, making them more powerful than a locomotive. The “super coder” can read through a chart faster than a speeding bullet. They may not be able to leap tall buildings, but they sure can find the principle diagnoses in a single bound.

The Clinical Documentation Improvement department is still fairly new to the hospital scene and the profession has gone through many changes even within that period of time. Coders have been an integral component throughout this transition and it is clear that these modest groups of individuals are SUPER!

Chemotherapy documentation challenges warrant CDI attention

Given the extremely high cost of chemotherapy services, it is likely that third-party payers, including Medicare, will scrutinize these services, says Glenn Krauss RHIA, CCS, CCS-P, C-CDIS, in an article for

Here is a breakdown of areas generally targeted by payers including Medicare and their related documentation difficulty:

  • Medical necessity for the supplied diagnosis: Often the clinician fails to provide the specific location of the cancer. A clinical documentation specialist can query the physician to ensure appropriate documentation.
  • Coverage exclusion for specific drugs based on clinical trial effectiveness:  Coders should reference local coverage determinations that generally spell out which diagnoses are considered covered benefits for common chemotherapeutic agents.
  • Proper charging and billing of drug units: Just documenting patients’ nausea and vomiting is not always sufficient to support payment of anti-emetic medicines.
  • Documentation to support IV administration units of service: Accurate coding for this requires clear start and stop times for IV chemotherapy administration. It is particularly problematic because clinicians do not always document the order of sequential therapy.

CDI programs might consider designating a team member specifically for the chemotherapy service line, Krauss says. A part-time specialist or member of the existing team may be enough depending on the monthly volume of patients in the chemotherapy department and the number of new patients who begin chemotherapy each month.

Focus initially on validating documentation and providing feedback to clinicians regarding documentation of IV therapy administration. The CDI specialist can help bridge the gap between customary medical record documentation and the level and detail of documentation necessary to properly and accurately capture all IV administration charges. subscribers can read the complete article online. 

No blarney, you’ve got the luck of the Irish

Feeling lucky?

Feeling lucky?

There’s not much time left in the good old Irish holiday of four leaf clovers and other Celtic mythologies. So before all your luck runs out, we here at ACDIS wanted to offer our own sort of celebration in the form of a quick contest.

It’s simple. We’ll  pick one random winner from those who leave a comment on this post to receive a free copy of “Coding and You: What every healthcare professional should know.” The handbook comes in packs of 10 so you can hand them out to finicky physicians or stubborn (not like the Irish) healthcare workers who don’t seem to understand the importance of coding and appropriate documentation yet.

We know sometimes the RSS feed doesn’t always post to your inbox right away so we’ll give you until noon Wednesday, March 18.

Good luck!

CMS cheat sheet on IPPS basics available

Page three and four of CMS’ revised Acute Inpatient Prospective Payment System Fact Sheet (January 2009) contains a number of pastel looking charts outlining what seems to be mathematical equations. These graphical details show how IPPS payments are derived through a series of adjustments applied to separate operating and capital base payment rates.

Although I don’t recommend it for bedtime reading, the Medicare Learning Network Payment System Fact Sheet should be on your CDI required reading list.

Maybe you’ve read it before, maybe you’re already well-versed in the IPPS process and know all about how DRGs became MS-DRGs and how the wage-index fits into the final cost analysis, but maybe all this sounds like you need an accounting degree or a master’s in business healthcare administration. Either way, it’s always good to keep an eye on what CMS says about its own systems.

Maybe make it your lunch-time reading instead.

Still inflamed by sepsis documentation? Listen in!

Bacteremia vs. septicemia; urosepsis vs. sepsis—who hasn’t experienced this documentation nightmare? Proper reporting of sepsis dramatically affects final MS-DRG assignment and hospital quality profiling. CDI specialists understand this. But what are the clinical indicators and how can we submit acceptable queries for these conditions.

If you missed the ACDIS February 5 audio conference  Sepsis Documentation and Coding: Clinical Indications, ICD-9 Guidelines, and Queries for Clarity Sample Sepsis Query featuring, James S. Kennedy, MD, CCS, from FTI Healthcare Brentwood, TN, and Jennifer Avery, CCS, CPC-I, CPC-H, a senior regulatory specialist from HCPro, Marblehead, MA, you can still order an audio-on-demand version of the show. 

Here’s a tip taken from the presentation: 

“If the physician only states ‘septicemia’ or ‘bacteremia,’ then query for clarification to determine if additional code assignment is appropriate for sepsis or SIRS. . . The coder should never assume that the presence of SIRS criteria on admission allows the coder to code 038.x as principal without corroborating physician documentation that sepsis was present on admission. This is especially important with Recovery Audit Contractors finding over $300 million in potential revenue their first year in existence.”

Download the free Sample Sepsis Query form courtesy of Wendy Dougherty, of Mercy Medical Center in Nampa, ID. ACDIS members have access to dozens of sample forms and useful tools in the Forms and Tools Library on the Web site. 

Visit our customer service department to become an ACDIS member.

The ICD-10 final rule is out!

Hi ACDIS members, today the HHS published a final rule to adopt ICD-10 as the new national coding standard. ICD-10 will take effect on Oct. 1, 2013.

This is obviously huge news for CDI specialists, physicians, and coding staff. Physicians will require additional education to ensure they are documenting to the level of specificity needed to support the new ICD-10 codes. Query forms and documentation templates will have to be reworked, presumably the CC/MCC list will be changing, and the list goes on and on.

To read an abbreviated ICD-10 fact sheet that contains a link to the final rule, click here.

Here at ACDIS we plan to provide educational articles, audioconferences, e-learning courses, and more to help with your transition to the new system. I also encourage you to offer your thoughts and impressions of ICD-10 right here by commenting on this post, or by posting to your colleagues on the CDI Talk group.

Take care everyone,