Coding Clinic Offers Important Guidelines For Coding Bmi

November 15, 2021

By junaid

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In Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments. Prepare yourself as this is rather lengthy due to continuation of NTAP that would normally expire.

Coding Clinic Offers Important Guidelines

Reporting of secondary and/or chronic conditions are often not reported for outpatient encounters. Omitting and/or failure to report these diagnoses do not paint a complete picture of the patient. Below, we will discuss some of the OCG’s for outpatient reporting. Separate guidelines are needed for coding interventional radiology procedures for inpatients and outpatients. For inpatients, determine if radiology guidance will be coded with ICD-10-PCS codes and if so, document the rationale for including the guidance. For outpatients, determine which procedures require the additional CPT code for radiology guidance. Many of the CPT codes include radiologic guidance and separate reporting is not appropriate.

Coding Tip: New 2022 Cpt Codes

Maybe you groan when you turn to an ICD-10-CM code and spot an Excludes1 note. You know the note means you’ll have to dig deeper to code the case correctly, but if you don’t really know how, you’re in good company. Ms. Leon-Chisen also stated thatCoding Clinicdoes not plan to publish a further clarification. Given the confusion and questions about the change we hope they will reconsider and offer additional specific guidance. Another final rule was issued on January 15, 2009, calling for the adoption of an updated version to the current HIPAA electronic transaction standards . The newer versions replaced the existing HIPAA transaction standards on January 1, 2012. Obtain knowledge on ICD-10-CM/PCS medical coding by registering for a live webinar.

  • Lately, we have seen missing PCS codes for the new technology drugs that were introduced on August 1, 2020 and thereafter.
  • Pneumonia is identified as the medical diagnosis on the therapy evaluation and plan of care to support the skilled therapy services along with the appropriate therapy treatment diagnoses.
  • Additionally, definitions have been added for some key words and terms used throughout the document.
  • Omitting and/or failure to report these diagnoses do not paint a complete picture of the patient.
  • Document other ancillary procedures (e.g., ECGs) that need to be captured at the facility.

Clarify if the exchange of lines is coded and how the codes are reported. Remember that the removal of lines is not a codable procedure.

Facilitate interdisciplinary education and collaboration in situations supporting proper documentation, reporting and data collection practices throughout the facility. Adhere to the official coding conventions and guidelines coding clinic offers important guidelines approved by the Cooperating Parties, the CPT rules established by the American Medical Association, and any other official coding rules and guidelines established for use with mandated standard code sets.

These include policies and procedures created by AHIMA, licensing and regulatory bodies, employers, supervisors, agencies, and other professional organizations. Examples 1-3 are documentation of diagnoses not supported by clinical indicators. Be responsible for updating, adding or deleting diagnoses to the patient problem list in the health record. Practices have not seen many revisions to the Evaluation and Management (E/M) office / outpatient visit guidelines in three decades – until now. We’ll get to those in a bit, but first let’s look at why they changed. Carotid artery disease is a vague category that can incorporate many different carotid artery issues.

Use Perforce Static Analyzers To Ensure Compliance With Coding Standards

The Standards of Ethical Coding are important established guidelines for any coding professional and are based on the American Health Information Management Association’s (AHIMA’s) Code of Ethics. Both reflect expectations of professional conduct for coding professionals involved in diagnostic and/or procedural coding, data abstraction and related coding and/or data activities. Other topics specific to outpatients that should be addressed in facility guidelines are the use of unlisted CPT codes or “Inpatient Only” procedures performed on outpatients. The facility guidelines should address any additional steps that the coding professional should perform when either situation arises. For example, if the coding professional assigns a total hip replacement CPT code on an outpatient and encounters the Inpatient Only procedure edit, what action is the coding professional expected to take? Does the coding professional verify that the patient is an outpatient? It is better to resolve these situations prior to dropping the claim.

Patient presents to the emergency room with abdominal pain in the upper left quadrant and during interview with the provider it is Certified Software Development Professional noted that the patient also has pain during urination. In this case, diverticulosis would be coded but not the abdominal pain.

Coding Clinic Offers Important Guidelines

Failure to thrive (adult – R62.7; child over 28 days old – R62.51) and underweight (R63.6) are considered weight diagnoses so the BMI is appropriate to report. For those who are reporting Hierarchical Condition Categories , remember that morbid obesity (E66.01) is an HCC and would be supported by the BMI. Morbid obesity and obesity (E66.9) are always reportable when documented by the provider.

Coding Tip: Carotid Artery Disease

And finally, information may become outdated due to the lack of annual review, with guidelines subject to individual interpretation. For example, a patient with Parkinson’s disease returns after a hospitalization for pneumonia to start a new Medicare Part A stay. Pneumonia is identified as the medical diagnosis on the therapy evaluation and plan of care to support the skilled therapy services along with the appropriate therapy treatment diagnoses. However, Parkinson’s disease is the reason for the continued facility stay and continues to be sequenced first on the record and the UB-04.

Coding Clinic Offers Important Guidelines

If there is a statewide trauma registry, some external cause codes will be required. The guidelines should also address if the external cause codes are required on every visit or only the initial visit (per the ICD-10-CM Official Guidelines for Coding and Reporting). Some state database commissions require the reporting for each visit that a traumatic injury/poisoning is treated. Healthcare claims reporting and formats should also be explored. The field locator or abstract field “Reason for Visit” has three spaces on the UB-04 . These field locators can be used to collect signs and symptoms which assist with meeting medical necessity. Determine who will collect this information (e.g., patient access or coding staff) and if you collect up to the maximum of three.

Some of these are HTN, COPD, asthma, emphysema and diabetes. It may be that some research is necessary to determine if the condition is one that has a cure or if it is one that they will have forever. Transfusion information is typically collected in the blood bank or the laboratory. If HIM staff is required to assign the transfusion procedure code for inpatients or outpatients, the guidelines should indicate Software maintenance which patient type is coded. For newborns, document if hearing tests, circumcisions, and vaccinations are captured as procedures. Identify documentation that may be used to capture body mass index , pressure ulcer stage, SDOH, coma scale, National Institute of Health Stroke Scale , and depth of non-pressure ulcers. This direction will result in consistency among the coding and clinical documentation staff.

Apply accurate, complete, and consistent coding practices that yield quality data. Assist and educate physicians and other clinicians by advocating proper documentation practices to improve the integrity and specificity that more accurately reflects the acuity, severity and occurrence of events. Query the provider when there is no clinical information in the health record prompting the need for a query. Foster an environment that supports honest and ethical reporting practices resulting in accurate and reliable data. Chronic diseases in the outpatient setting should be reported. If a condition is under current treatment it should be reported for each visit as long as the patient is receiving treatment for the condition. Remember though that there are chronic diseases that are systemic conditions and the patient will have them for the remainder of their life.

American Health Information Management Association Standards Of Ethical Coding

While most facilities have specific coding guidelines, they’re usually undocumented. As a result, new coding professionals are usually left with no choice but to learn about the facility guidelines by talking with the tenured coding staff.

Coding Clinic Offers Important Guidelines

These types of instances may require referral per the facility’s internal escalation policy. Facilities should also work with their medical staff to ensure conditions are appropriately diagnosed and documented. The facility should assign the appropriate code for the conditions documented. Encephalopathy is a general term and means brain disease, brain damage or malfunction.

Terms For Principal Diagnosis

In this case, a code for the COPD exacerbation would be reported as well as “Z” codes for personal history of pneumonia, history of smoking, and family history of lung cancer and colon cancer. All of these histories are pertinent and help to describe the patient’s history and possible future workups needed. Query documentation may be included in the legal record or may be filed separately. This should be specified in the facility-specific guidelines. If it is filed separately, the physician would document the response to the query in the clinical documentation as an addendum.

Remember, you absolutely can have your physician advisor set clinical criteria for when a query should be placed. Query criteria are unrelated to the problem of code assignment based on clinical criteria. We certainly do want our physician advisors involved in the use of appropriate criteria for query purposes in order to avoid unnecessary, unreasonable, or leading query practices. Chronic systemic conditions should be reported even in the absence of intervention or further evaluation.

The code explains that the patient was placed on comfort measures. Also, it is best to report the code in the top ten positions to ensure that it will be considered by the third-party payer when the claim is processed. The status codes describe a history of a procedure (e.g., amputation) or the presence of a medical implanted device (e.g., pacemaker). For example, estrogen receptor status (Z17.-) may be captured with breast cancer (C50.-). Successful facility-specific guideline creation requires preparation. There are several topics to review and finalize prior to writing the guidelines. A collaborative approach, inclusive of all relevant hospital departments, is recommended—decisions should not be made by the coding manager alone.

Physicians often use encephalopathy and altered mental status interchangeably. When coders see this documentation in the healthcare records, they typically need to query the physician for clarification of the diagnosis. Patient presents for outpatient visit for difficulty silverlight breathing. The patient has COPD and has had pneumonia several times in the past couple of years. The patient does have a history of smoking and a family history of father with lung and colon cancer. The final impression by the physician is COPD exacerbation.

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