Viewing posts categorised under: ICD-10 CM

New ICD-10 Code Updates: Ask the Right Questions to Get the Right Code

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Clinical Documentation Improvement, Clinical Practices, Coding, Healthcare, ICD-10 CM, OASIS-C2, Uncategorized

New ICD-10 Code Updates: Ask the Right Questions to Get the Right Code

CMS releases updates to the ICD-10-CM coding manual

 
Every October, the CDC and CMS release updates to the ICD-10-CM coding manual. These updates include both codes in the tabular and alphabetical indexes as well as official guideline changes. The following is a summary of some of those changes that Home Health Agencies need to know about.
  • Non-pressure ulcers now have 3 new code subcategories to include those ulcers that are down to the muscle or bone but do not have necrosis and for those ulcers that have tendon/ligaments showing. The clinician should always document the severity of the non-pressure ulcer in terms of skin breakdown, fatty layer, muscle exposed, muscle exposed with necrosis, bone exposed, bone exposed with necrosis, or other appropriate descriptive terms (tendon/ligament, hard eschar, slough obscuring wound bed, etc.).
  • C Diff is now being captured as being recurrent or not stated as being recurrent. Recurrence is defined by complete resolution of C diff symptoms while on appropriate therapy, followed by subsequent return of diarrhea and other symptoms after treatment has been stopped. Recurrence usually occurs within one week after treatment stops but may happen up to 8 weeks later. The physician would need to confirm whether C diff is recurrent or not.
  • Types of myocardial infarctions now play a role in determining the appropriate ICD-10 code. Type 1 is the most common MI which is associated with ischemia and due to primary coronary even. Type 2 MI is due to imbalance in supply and demand of oxygen. Type 3, (which we wouldn’t see in home health), is sudden cardiac death, including cardiac arrest. Type 4 MIs are associated with percutaneous coronary intervention while type 5 MIs are associated with a CABG procedure.
  • Secondary pulmonary hypertension diagnosis code has been further detailed to describe what the condition is that is causing the secondary pulmonary hypertension, including left heart disease, lung disease, etc.
  • Lumbar stenosis should be classified with or without neurogenic claudication. Neurogenic claudication is leg pain with walking. The physician must confirm neurogenic claudication for it to be coded.
  • Bowel obstructions can now be captured as complete or incomplete/partial. Complete bowel obstructions would need surgery to correct while incomplete/partial bowel obstructions can be sent home for it to resolve. The coding specialists need to know whether a bowel obstruction is resolved upon discharge from the hospital. Resolved conditions cannot be coded in home health except for in OASIS items M1011 and M1017 when they reflect the patient’s recent history.
  • New coding guidelines state that if a patient’s visual category is not documented then coding specialists can only code unqualified visual loss. It would be beneficial to query the physician to determine patient’s visual category to be more specific with coding of low vision and blindness. Also, the laterality of the low vision and blindness is necessary in retrieving the most specific code.
Along with these changes come the need for increased specificity for diagnoses. To assign specified codes, coding specialists rely on clinicians and physicians to provide adequate detailed information about each diagnosis being listed on the plan of care. Without this important step, coding specialists are left to code only unspecified diagnoses, which could impact reimbursement, or cause a delay in coding as a query may be necessary. To reduce queries to your clinical leadership and clinicians, here are some tips on being proactive with detailed information:
  • Query the provider for specifics that are not included in the physician documentation prior to completing assessment.
  • Specify sites and laterality of wounds
  • Specify etiology of wounds (surgical, traumatic, diabetic, arterial, venous, etc)
  • Query the provider for late effects of CVA if there are none documented in clinical paperwork
  • List the type of MI the patient experienced
  • Always document patient’s smoking/tobacco use status (current or history of, and what product)
  • Don’t list diagnoses on the plan of care that are not actively being addressed or impacting the plan of care
  • If there are diagnoses listed on the plan of care that will likely impact it, but no direct interventions regarding those conditions are present, document how they will impact the POC
  • Document if patient’s substance disorders are in remission per physician documentation or query to determine this.
  • Document the specific type of heart failure a patient has been diagnosed with
  • Specify which type of diabetes a patient has been diagnosed with, and what, if any, manifestations are present.
For the coding specialists to capture more specific diagnoses based on the clinician’s documentation, clinicians should document in the clinical note that this specific information was provided by the physician. Clinicians can document specificity but unless there is verbiage stating that the condition is physician confirmed, the coding specialists cannot code that specific condition. Select Data enjoys working closely with clinicians to provide the codes being captured in the plan of care. It is truly a team- work experience. If you have any OASIS review or Coding questions please call Select Data at 1.800.332.0555.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.

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OASIS C2 and Active Diagnoses: Are Your Agency’s Answers Setting You Up for Potential Issues?

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Clinical Practices, Coding, Conditions of Participation (CoPs), ICD-10 CM, OASIS-C2

OASIS C2 and Active Diagnoses

Are Your Agency’s Answers Setting You Up for Potential Issues?

 
OASIS C2 has proven to have caused difficulty for many agencies. One key reason is M1028. Agencies must remember that a physician must validate if a patient has diabetes and/or PVD/PAD. In addition, the physician must determine if the diagnosis is active. The clinician cannot make that determination.   The OASIS Manual explains that these diagnoses influence the patient’s functional outcomes or risk for developing pressure ulcers. These are keen areas of concern to CMS. As a result, CMS is paying close attention to active diagnoses. Conditions that are resolved are not listed. Most patients with diabetes or PVD/PAD will have those as an active diagnosis but a clinician must not jump to conclusions. A physician must confirm the diagnosis is active and the agency should note that confirmation date.   The Clinical/Coding specialists should review the patient’s clinical record carefully for documentation to support the diagnosis and the plans for care. Review the medication profile, the comprehensive assessment, and the visit notes for related information as well as for congruency between the documentation. Pay close attention to M1028 but also to all active diagnoses.   Per CMS, active diagnoses are diagnoses that have a direct relationship to the patient’s current functional, cognitive, mood or behavior status; medical treatments; nurse monitoring; or risk of death at the time of the assessment. Note that CMS is honing in on the functional, cognitive, and behavioral status of the patients. It appears they are looking closely at active diagnoses, certain specific diagnoses, as well as the assessment of the patient…a very comprehensive assessment. They expect the assessment to support the diagnoses.   In the new Conditions of Participation (CoPs), CMS states that the “comprehensive assessment must identify the psychosocial, functional, and cognitive status of the patient including evaluating and screening any patient psychological and social condition that may complicate HHA service delivery or inhibit the patient’s ability to understand, remember, and participate in developing and implementing the plan of care.”   In summary, carefully answer M1028 but note all diagnoses must be confirmed by a physician. Be certain those confirmations are documented. Expand your comprehensive assessment to have a detailed psychosocial, functional, and cognitive assessment.   Remember, assessment and diagnoses are a focus of CMS. Make them your focus also.  For expert documentation review and coding, contact the Select Data Specialists.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians Click here to read more.

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What is Medical Coding? – Coding and OASIS Review Services

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Clinical Documentation Improvement, Clinical Practices, Coding, Healthcare, ICD-10 CM, OASIS-C2

What is Medical Coding? - Coding and OASIS Review Services

With the implementation of ICD-10 have we seen an increase in patient outcomes?

 

ICD-10

Since the implementation of ICD-10 by the Centers for Medicare & Medicaid Services (CMS) on October 1, 2015 have we seen an increase in the shear number of procedural and diagnosis codes. Currently, there are 68,000 ICD-10-CM codes and 87,000 ICD-10-PCS codes compared to 14,000 ICD-9-CM codes and 4,000 ICD-9-PCS codes available (ACR, 2012). Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician's notes, laboratory and radiologic results, etc. (AAPR, 2017). But, have we seen an increase in patient outcomes?

Quality Outcomes Matter

Luckily for our clients, Select Data had been preparing for the ICD-10 increase of codes months prior to the implementation. In addition, our professional medical coders & billers have an average of 8+ years of Coding experience. Furthermore, the Select Data Coding and  OASIS Review service improved revenue for our clients on average of 6% and a reported 40% reduction rate in hospital readmissions.

Our Process

It is not enough to review the entire integrated OASIS assessment for completeness and conguency. We query the agency clinician on incongruencies between the physician orders, clinical record and patient's condition. Our process changes the behavior because we engage the clinician when suggesting changes. So that you can focus on patient outcomes.

Our Motto

Driving outcomes guided by compassion, values and a sense of stewardship. Because patients are more than a number. Each deserves their own portrait. At Select Data, we code with an artist's brush, not a rubber stamp. We help you focus on patient outcomes. Check out our Coding and OASIS Assessment review services today!

Helpful Tip


With over 20 years of professional coding service experience in and   is uniquely qualified to mitigate operational challenges.

References AAPC (2017). What is Medical Coding? Retrieved from: https://www.aapc.com/medical-coding/medical-coding.aspx American College of Radiology (2012). Prepare Now for ICD-10-CM and ICD-10-PCS Implementation. Retrieved from: https://www.acr.org/Advocacy/Economics-Health-Policy/Billing-Coding/Prepare-Now-for-ICD10  

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ICD-10-CM is Finally Here… what now?

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Coding, ICD-10 CM

October 1, 2015, began the live implementation of ICD-10 across the healthcare continuum of care. After years of planning and delays, the greater expansion of codes and more sophisticated architecture presents the ability to have increased specificity of detail of disease and condition capturing patient acuity with improved detail and accuracy… finally. It has been a 20 year journey. Errors from incorrect coding are now very real, as 69,000 new ICD-10-CM codes vs 16,000 ICD-9-CM codes enter the playing field. Some agencies mistakenly believed the General Equivalency Mapping (GEMs) from ICD-9-CM to ICD-10-CM would be a direct crosswalk only to learn later that the crosswalk was meant to be a user tool for assisting coders to make their coding decisions based upon patient care needs and care complexity. It should be noted that some physicians were given a one-year leeway, but be careful. That July 2015, CMS regulatory guidance stated that for one year after Oct. 1, 2015, Medicare would not deny Part B claims from physicians or other practitioners “based solely on the specificity of the ICD-10 diagnosis code,” as long as providers use valid codes “from the right family.”  First of all, note this applies to Part B only and also, what does “from the right family mean?” The “family of codes” is the same as the ICD-10 three-character category states the CMS FAQ, but there is more involved. One aspect noted quickly is that with the increased specificity and complexity of the codes, coding specialists must spend additional time abstracting information from the clinical record. A lack of adequate clinical documentation can result in delays as the coder must confirm the inconsistent, inadequate, or incongruent information. Are your coding specialists proficient on what documentation is needed for each diagnosis? For example: If the diagnosis is COPD, was it an acute exacerbation? Decompensated?. Is there an acute respiratory infection? If yes, what organism? And of course there are 6 other items to clarify. For ALL of your ICD-10-CM Coding needs and to educate your clinicians as to specific documentation needed to code ICD-10-CM diagnoses, contact Select Data at 1-800-332-3555    

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466 actions you need to complete BEFORE ICD-10 goes live

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Coding, ICD-10 CM

With the implementation of ICD-10 scheduled to take place October 1, 2015 the question looms, has your agency properly prepared? CMS has stated that ICD-10 “may result in significant impact to cash flow. This may require the need for reserve funds or lines of credit to offset cash flow challenges.” CMS anticipates a 10% revenue hit due to coding specificity errors.   ICD-10 requires that all coders be aware of an additional 53,000 codes. These codes are alphanumeric, may be up to 7 characters in length, are HIPAA compliant, and have a different structure with far more specificity. CMS already predicts that 10% of all claims will be rejected within the first 90 days of ICD-10 implementation due solely to errors in coding specificity. You need specialists to assist you in preparing for ICD-10 CM

  • Your agency should have already established an ICD-10 team as well as completed a GAP Analysis by the end of 2013.
  • A complete audit of your agency should be completed within the first few months of the New Year.
  • Clinician documentation will need to be clear, in-depth, and specific to comply with ICD-10 standards.
Our Audit Team can perform a coding review for your agency conducted by our Chief Corporate Compliance Officer and our Coding Quality Analyst, both on staff. Our team will begin parallel coding summer of 2014, months before ICD-10 goes live, in preparation. Our coders can help your agency make this transition a smooth one. An increasing number of home health and hospice agencies are preparing to have a third-party group of specialists handle this major change that could dramatically impact the financial well-being of their firm. Let the MasterCoding™ specialists at Select Data provide your coding and assist your clinical team in preparing for this huge process change. Do not be caught off guard with rejected claims and coding confusion. It is essential to prepare for ICD-10 now. Call Select Data.  

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