Implemented on March 5, 2018, CMS relaxed the teaching physician guidelines to allow for broader usage of medical student documentation. Previously, CMS restricted student documentation to solely recording the review of systems (ROS) and past medical, family, and social history (PFSH). The teaching physician would need to document or re-document any other aspects of the visit. The update allows the teaching physician to utilize the student’s documentation of the entire visit.Read More
Capturing maximum E/M revenue should always be the goal while coding major surgeries and modifier 57 can help.Read More
The 2017 ICD-10-CM is looking a bit more like ICD-9-CM thanks to the addition to some codes that were forgotten in the first release. As a heavy user of external cause codes and an ED coder at heart, I was so accustomed to using the E927 series that when ICD-10-CM came out I felt lost and forgotten. They may have forgotten the highly used code series; but fear not, they remembered them this year.Read More
Did you know almost one fifth of the US population lives in a rural area? Critical Access Hospitals, otherwise known as CAHs, make up nearly 30% of the nation’s acute care hospitals. The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities.Read More
Lumbar spinal fusions are among the most challenging procedures to code, partly because the anatomy is difficult to conceptualize and due to the variety of approaches and combinations of procedures that can be done.
Let’s focus on fusion of the anterior column of the lumbar spine. That’s fusion of the joint (yes, the disc forms a “lower joint”) between the vertebral bodies. Whenever you see an “interbody fusion” you know you’re looking at an anterior column spinal fusion.Read More
Sepsis – every coder’s best friend! Many of us have faced the challenge of reconciling the variations that exist in defining sepsis between ICD-9, ICD-10, providers as a group, and even amongst providers at a single hospital. Change is in the air.
The most traditional concept of sepsis is a bacterial infection of the blood (septicemia) and the havoc this wreaks on the body. Indeed ICD-9 and ICD-10 both fit best to this idea as the codes for sepsis are found squarely among the bacterial infectious disease codes. Of course ICD-10 arguably clarified the situation somewhat...Read More
Question: I’m seeing a lot of physicians assigning diabetes with hyperglycemia for “uncontrolled” diabetes. Somehow this doesn’t seem right. Could someone explain to me what the criteria for hyperglycemia is?
Answer: Hyperglycemia has no strict definition and varies from patient to patient in different situations. Anything over a blood glucose over 100 can be considered “hyperglycemia”. In practice...Read More
Often times we find ourselves in a same old, same old place due to safe career choices. We find ourselves in a comfortable job where everything is familiar and routine. It’s fine for a while, but eventually it gets rather boring. How did this happen to me? How did I get myself in such a rut? If this sounds familiar, it may be time for a change!
A smart move would be to consider a career in Health Information Management (HIM). The HIM industry is growing by leaps and bounds and there are many career paths in this dynamic field.Read More